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Page 1: conferences / seminars / symposia

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Page 2: conferences / seminars / symposia

INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 i

eISSN – 2348 – 0173 : pISSN-2395-3985

Editor –in Chief Dr. Swati D. Bhingare

BAMS, MD (Ayu) Email : [email protected]

Executive Editor Dr. Dhanashri H. Mahajan

BAMS, MS (Ayu)

Associate Editors

Dr. Ranjeet S. Sawant Assistant Professor

Dept. of Rasashastra & B.K. KGMP Ayurved College, Charni

Rd., Mumbai (Maharashtra)

Dr. Manish S. Bhoyar Assistant Professor

Dept. of Rasashastra & B.K. Govt. Ayurved College, Nagpur (Maharashtra)

Dr. Sandeep V. Binorkar Assistant Professor Dept. of Agadatantra

Govt. Ayurved College, Nanded (Maharashtra)

ADVISORY BOARD MEMBERS

Dr. Amitabh Kumar

Vice-President - Ayurveda Central Council of Indian Medicine

New Delhi, India

Dr. Mary Smitha Golden Kiwi Ayurveda Health Centre Member of New Zealand Ayurvedic Association and Natural Health Practitioners, Auckland, New Zealand

Prof. K. R. Kohli Director of AYUSH, Govt. of Maharashtra, Fort,

Mumbai – 431001 India

Dr. Neeta Mahesekar Professor, Head of the Department (Ob. & Gy.), Dange Ayurveda Medical College, Ashta, Maharashtra, India

Prof. Laxmikant Dwivedi Dept of Rasashastra & BK, GJAC & RC,

New V. V. Nagar, Anand, (Gujarat) – 388121

India

Dr. Anand B. Kulkarni Professor & Head, Dept. of Agad Tantra & Vyavahar Ayurved, B.S.D.T’s Ayurved Mahavidyalaya, Wagholi, Pune- 412207 India

Prof. Shrikrishna Sharma (Khandel) Europa University, Viadrina, Frankfurt Oder, Germany,

Naturafarm GmbH, Togo st, Berlin

Prof. A.P.G. Amarasinghe Professor, Institute of Indigenous Medicine (IIM) University of Colombo, Rajagiriya, Sri Lanka

Joerg Gruenwald Analyze & realize GmbH,

Waldseeweg 6, 13467 Berlin, Germany

Shanmugamurthy Lakshmanan Vice President for International Research & Distinguished Scientific Advisor, World Institute for Scientific Exploration, Baltimore, MD & Research Scientist, Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Meical School, Boston, USA

Dr. Babasaheb Patil Professor & Principal I/c

B.S. Ayurveda College, Sawantwadi Maharashtra

Dr. A.B. Pant Senior Scientist & I/c In Vitro Toxicology, CSIR-Indian Institute of Toxicology Research, Lucknow-226001 (UP)

*****

Page 3: conferences / seminars / symposia

INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 ii

eISSN – 2348 – 0173 : pISSN-2395-3985

EDITORIAL BOARD MEMBERS

Dr. Dilip K. Jani Associate Professor & Head, Department of Dravyaguna,

G. J. Patel Ayurved College, New Vallabh Vidyanagar, Anand-388121, Gujarat

Dr. Guruprasad Assistant Professor, Department of Swasthavritta Sri Jayendra Saraswathi Ayurveda College & Hospital Nazarathpet, Chennai, Tamilnadu - 600 123

Dr. Sanjeev Rastogi

Associate Professor and Head Dept of Pancha Karma, State Ayurvedic College &

Hospital, Tulsi Das Marg,Lucknow -226004

Dr. Pooja Kohli Ayurveda Expert Central Council of Indian Medicine (CCIM) Janakpuri, New Delhi, INDIA

Dr. Manojkumar Shamkuwar

Lecturer, Department of Panchakarma A & U Tibbia College & Hospital, Karol Bagh, New Delhi

Dr. Ajay Gopalani Ayurveda Consultant Shah Satnamji Speciality Hospitals Sirsa - 125055, Haryana

Dr. Ashvin Bagde

Asst. Professor, Sanskrit, Samhita Siddhant, Govt. Ayurved College,

Osmanabad (Maharashtra)

Dr. Pramod C. Baragi Reader, Dept. of Rasashastra & BK N. K. Jabshetty Ayurvedic Medical College Manhalli Road, Gumpa,Bidar-585401 (Karnataka)

Dr. Anuradha Patil Associate Professor,

Dept of Rasashastra & Bhaishajya Kalpana, L.R.P. Ayurvedic Medical College, Islampur,

Dist. Sangli

Dr. Kamini Kaushal Professor,Dravyaguna Department, Rishikul Govt. Ayurvedic PG college, Haridwar (UttaraKhand) INDIA

Dr. K. Ravindra Bhat

Assistant professor, Dept. of Kayachikitsa, Karnataka Ayurveda Medical College, Ashoknagar,

Mangalore Karnataka

Dr. Umapati C. Baragi Associate Professor, Dept. of Basic Principles, S.D.M. College of Ayurveda, Udupi, Karnataka

Dr. Harish Kumar Singhal

Assistant Professor, Department of Kaumarbhritya Dr. S. R. Rajasthan Ayurved University,

Jodhpur, Rajasthan

Dr. Vijaykumar D. Nandvadekar Associate Professor Department of Kriya Sharir, Gomantak Ayurveda College, Vazem, Shiroda, Goa

Dr. Kiran Nimbalkar

Lecturer, Department of Agadatantra A & U Tibbia College & Hospital, Karol Bagh, New Delhi

Min-hui Li National Resource Center for Chinese Materia Medica China

Dr Yogita Shrivas

Professor, Department of Kaumarbhritya Government Ayurved College, Nagpur

Maharashtra

Dr. Yogesh S. Deole Assistant Professor & Consultant Dept. of Kayachikitsa, G. J. Patel Ayurved College, New Vallabh Vidyanagar, Anand-388121, Gujarat

*****

Page 4: conferences / seminars / symposia

INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 iii

THE JOURNAL: International Journal of Ayurveda & Alternative Medicine (IJAAM) is a peer reviewed scientific open access professional journal, publishing full-length original research papers and reviews on Ayurveda, Complementary & Alternative Medicine and allied health disciplines. The journal endow with an inter-disciplinary platform for linking contemporary & traditional knowledge with the most recent developments in scientific world. IJAAM will explore disciplines like Ayurveda, Yoga, Naturopathy, Pharmacognosy, Botany, Ethnobotany, Ethnomedicine, Taxonomy, Ethnopharmacology, Biology, Biotechnology, Medicinal Chemistry, Pharmacology, Clinical Pharmacology, Phytochemistry, Clinical Research, Animal Experiments. All manuscripts contributed to IJAAM will be subjected to rigorous editorial & double blind expert peer review process considering that the same have not published previously and also are not under consideration for publication elsewhere. AIM & SCOPE: International Journal of Ayurveda & Alternative Medicine (IJAAM) publishes original scientific research reports, case reports, short communications, letters to the editor and reviews which cover significant new findings in all areas of Ayurveda and Alternative health care sciences (including epidemiology, public and environmental health). Book reviews, scientific news and conference proceedings are published on special request. IJAAM follows stringent guidelines to select the manuscripts on the basis of its originality, importance, timeliness, accessibility, grace and astonishing conclusions. IJAAM is also popular for rapid publication of accepted manuscripts. Interested authors / contributors are requested to follow the guidelines for preparation and submission of manuscripts as detailed in the section "Author's Guidelines" on www.ijaam.org. Apt implementation of the guidelines will help to speed up the processing and review of manuscripts. ABOUT THE EDITORS: IJAAM management team is very particular in selecting its editorial board members. Editorial board members are selected on the basis of expertise, experience and their contribution in the field of Ayurveda & other Alternative Systems of Medicines. Editors are selected from different countries and every year editorial team is updated. All editorial decisions are made by a team of journal management professionals. ABSTRACTING AND INDEXING INFORMATION: IJAAM is indeed with abstracts on DRJI, Cite Factor, Global Impact Factor, Google Scholar, Indian Science, Research Bible, Scientific Indexing Services, Scientific Journal Impact Factor, International Impact Factor Services, Open Academic Journals Index, International Society for Research Activity, International Scientific Indexing (UAE) Polish Scholarly Bibliography & Index Copernicus (Under Evaluation) THE EDITORIAL PROCESS: The manuscript along with Copyright form should be submitted to IJAAM only which has not been published

earlier or which is not sent to other journal / magazine office for publication at the same time. Editor / Editorial Board members will be the first personnel to review all the submitted manuscripts. Editors have the right to reject those submissions which do not fulfil fundamental requirements and lacks in originality with technical or scientific deficiencies or do not carry a scientific message. Acknowledged submissions will be forwarded to 3 or more reviewers after depending on the topics. The identity of the author will be masked to ensure double blind review. After the reviewers’ comments on the manuscripts, the same shall be forwarded to the authors for the suggested rectifications. IJAAM is committed to the speedy processing o the articles targeted to completed within 3-5 weeks. Finally accepted articles are edited for the grammar, punctuations, print style & format. The Galley proofs of such edited manuscripts will be sent to the respective authors and they have to go through it thoroughly to make final corrections if required and return the same within a period of 2 days. Author can suggest the name of reviewers who he feels has experience in the fiend but are not from the same institute as the author. The final selection of the reviewer is done only by the Editor/Editorial board. TYPES OF MANUSCRIPT & LIMITS: Original Articles: The text limit in this category is 15 pages and does not include references. Abstract up to 250 words is a must. Under this category one can publish randomized controlled trials, intervention studies, studies of screening and diagnostic test, outcome studies, cost effective analyses, case controlled series and surveys with high response rate. Review Articles: The text limit in this category is 20 pages and does not include references. Abstract up to 250 words is a must. It is mandatory to include the method (literature search) in abstract as well as in the introduction section. Research Methodology: This section should include educative articles which will educate fellow contributors on the nuances of research. The limit of such articles is 15 pages and does not include references. Abstract up to 250 words is a must. Brief Communication: Though they are much like original articles they have certain limitations in the study. The limit of such articles is 5 pages and does not include references. Abstract up to 250 words is a must. Case Report: Interesting cases which are very significant will come under this category. The purpose of reporting the case should be mentioned in the introduction. The limit of such articles will be 5 pages and does not include references. Abstract up to 250 words is a must. Letter to the Editor: This section should be short and decisive observation and should not require any further

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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 iv

paper for validation. The limit of such articles will be 2 pages and does not include references. Symposia: Will include commissioned articles from the editorial board. AUTHORSHIP CRITERIA: A person can be author when he /she make an important and substantial contribution towards the making of the article in relation to the content, concept, data, its analysis and its interpretation. All authors should be in a position to take public responsibility for the contents of the article. The order of naming the authors should be based on the relative contribution of the authors towards the study and writing the manuscript. Number of contributors should not be more than six. No change in the order of names or inclusions as author will be done unless it is supported by the written consent of all the contributors. No change will be permitted after acceptance of the article. The contributors should keep the editorial office updated on the happenings regarding the subject post publication, like progress made in the field or even certain related major developments. They are requested to send an update on the same under “Letter to Editor” to the editorial office. INSTRUCTIONS FOR AUTHORS: Electronic submission of manuscripts is strongly encouraged, provided that the text, tables, and figures are included in a single Microsoft Word file. You may also submit manuscripts as e-mail attachment to the journal Office at: [email protected] A manuscript reference number will be mailed to the corresponding author within three working days. The cover letter should include the corresponding author's full address and telephone/fax numbers and should be sent to the Editor, with the file, whose name should begin with the first author's surname, as an attachment. Title: The Title should be as brief as possible describing the contents of the paper. The Title Page should include the authors' full names and affiliations, the name of the corresponding author along with phone, fax and E-mail information. Present addresses of authors should appear as a footnote. Abstract: The Abstract which should be included at the beginning of the manuscript should be informative and completely self-explanatory, briefly present the topic, state the scope of the experiments, indicate significant data, and point out major findings and conclusions. The Abstract should not be more than 250 words in length. Complete sentences, active verbs, and the third person should be used, and the abstract should be written in the past tense. Following the abstract, about 3 to 6 key words that will provide indexing references to should be listed.

Key Words: About 3 to 5 key words that will provide indexing references should be listed Abbreviation: Each abbreviation should be spelled out and introduced in parentheses the first time it is used in the text. Only recommended SI units should be used. Introduction: The Introduction should provide a clear statement of the problem, the relevant literature on the subject, and the proposed approach or solution. It should be understandable to colleagues from a broad range of scientific disciplines. Materials and methods: Materials and methods should be complete enough to allow experiments to be reproduced. Only truly new procedures should be described in detail; previously published procedures should be cited, and important modifications of published procedures should be mentioned briefly. Subheadings should be used. Methods in general use need not be described in detail. Results: Results should be presented with clarity and precision. The results should be written in the past tense when describing findings in the authors' experiments. Previously published findings should be written in the present tense. Results should be explained, but largely without referring to the literature. Discussion: Discussion, speculation and detailed interpretation of data should not be included in the Results. The Discussion should interpret the findings in view of the results obtained in this and in past studies on this topic. Conclusions: State the conclusions in a few sentences at the end of the paper. Acknowledgments: The Acknowledgments of people, grants, funds, etc should be briefed. Tables: Tables should be simple and kept to a minimum. Tables should be typed single-spaced throughout, including headings. Tables should be self-explanatory without reference to the text. Figure: Figures on a separate sheet. Graphics should be prepared using applications capable of generating high resolution JPEG or Powerpoint before pasting in the Microsoft Word manuscript file. Tables should be prepared in Microsoft Word. Use Arabic numerals to designate figures and upper case letters for their parts. References: References should be cited in the article continuously according to appearance in Arabic numerical superscript in square bracket. (Not in alphabetical order) Book reference: Sharma PV, Guru Prasad Sharma, editors. Dhanvantari Nighantu. 4th ed. Varanasi: Chaukhambha Orientalia; 2005.p.78. Article reference: Winter CA, Risley EA, Nuss GW. Carrageenan induced edema in hind paw of rat as an

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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 v

assay for anti inflammatory drugs. Proc Soc Exp Biol 1962; (111):544. Website reference: http://www.weebly.com/weebly/instructionsforauthors.php [Accessed date 25.10.2013] Ethical Guidelines: Studies on human beings should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975, as revised in 2000 (http://www.wma.net/e/policy/17-c_e.html) A statement on ethics committee permission and ethical practices must be included in all research articles under the 'Materials and Methods' section. Evidence for approval by a local Ethics Committee (for both human as well as animal studies) must be supplied by the authors on demand. The ethical standards of experiments must be in accordance with the guidelines provided by the CPCSEA and World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Humans for studies involving experimental animals and human beings, respectively). The journal will not consider any paper which is ethically unacceptable. Processing Fee / Charge: There are no fee / charges for initial submission of manuscript and for its evaluation. Only on acceptance of the manuscript after peer review, corresponding author will have to pay nominal amount /charges for processing, handling, editing, indexing and web maintenance. The mode of payment will be informed by mail to the corresponding author. Merely a submission of manuscript does not guarantee the final publication until and unless the manuscript pass all the required criteria and peer review. ADVERTISING POLICIES IJAAM accepts and display classified advertisements from the pharmacies, hospitals and manufacturers of

medical equipments. Discounts on frequent publications and special positions are available on request. Further inquiries about advertising can be sent to [email protected] IJAAM reserves the right to accept or reject Copyright: The entire contents of International Journal of Ayurveda & Alternative Medicine (IJAAM) are protected under Indian & international copyrights the journal however grants to all the users a free unalterable worldwide uninterrupted right to access to and a licence to copy, use, distribute and display the work widely in any digital medium for any reasonable non-commercial purpose, subject to proper attribution of authorship and ownership of the rights. The IJAAM also grants the right to make small number of printed copies for their personal non commercial use. Disclaimer: The information and opinions published in the IJAAM reflects the views of the authors only and not of the journal or its editorial board or publisher. Publication does not constitute endorsement by the IJAAM. Neither the International Journal of Indian Medicine nor the publishers including the persons involved in creating, producing or delivering assumes any liability or responsibility for the precision, completeness or usefulness of any information provided in the journal. IJAAM shall not be responsible for any direct, indirect or consequential damages arising as a result of use of information published in IJAAM. Readers are hereby requested to confirm the information contained herein with the other relevant and reverent sources. Address for Communication: Editor-in-Chief International Journal of Ayurveda & Alternative Medicine (IJAAM) # 401/8-A, 4th Floor, Shiv Shrishti Apt. Nardas Nagar, TP Rd., Bhandup (W), Mumbai – 400078 (Maharashtra) INDIA Email: [email protected]

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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 vi

INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE (IJAAM) IS INDEXED / CITED IN

FOLLOWING DATABASE 1. National Library of Medicine (NLM) Division of

NCBI (PubMed) USA (NLM ID - 101637632) 2. AYUSH Portal - Evidence Based Research Data of

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Research Centre Berlin 40. Open Access Journals Search Engine (OAJSE) 41. Green Pilot 42. Sonic Run 43. ISEDN 44. Exact Seek 45. Polish Scholarly Bibliography 46. Directory of Open Access Journals (DOAJ) - (In

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Resources 58. Portal on Central Eastern & Blkan Europe (PECOB) 59. International Journal Impact factor IJIF 60. Directory of abstract indexing for Journals

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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 vii

CONTENTS

Article

No. Title & Author Page No

REVIEW ARTICLES

1 STUDY OF DHATUPRADOSHAJA VIKAR W.S.R.T. RAKTADHATUPRADOSHAJA VIKARA: A LITERERY REVIEW 116-122

Prashant R. Shirke1*, Parag N. Deshmukhe2, Ravikumar B. Patil3, Milind C. Kirte4,Deepak P. Sawant5

ORIGINAL RESEARCH ARTICLE

2 ROLE OF KSHARSUTRA (PREPARED ACCORDING TO RASATARANGINI) IN BHAGANDARA WITH SPECIAL REFERENCE TO FISTULA-IN-ANO 123-132

Ukhalkar V. P.1*, Pradnya Morwadkar (Vedika V. Bhoir) 2

3 EFFECT OF DIFFERENT INTERVALS OF YOGA AND NATUROPATHY TREATMENTS ON DISEASE ACTIVITY SCORE, SYMPTOM SCORE, RHEUMATOID FACTOR, URIC ACID AND KIDNEY FUNCTION TESTS IN PATIENTS SUFFERING FROM RHEUMATOID ARTHRITIS

133-140

Ranjna Chawla1*, Aparna2, Rukamani Nair3

4 EFFECTIVENESS OF ROOT DECOCTION OF Indigofera tinctoria ON PEPTIC ULCER (GUNMAM) 141-148

Paheerathan V.1*, Pawmitha. M.F.F.2

5 INTEGRATED APPROACH OF YOGA, NATUROPATHY AND PHYSIOTHERAPY IN THE MANAGEMENT OF OSTEOARTHRITIS OF KNEES 149-155

Rukamani Nair1, Naorem Jiteswori Devi2*, Gaurav Kaushik3, V.N. Gaur4, Akhil Jain5

CASE REPORT

6 PAIN MANAGEMENT BY PANCHAKARMA THERAPY W.S.R. TO CHRONIC LOW BACKACHE – A CASE STUDY 156-159

Bhingardive Kamini B.1*, Sarvade Dattatray 2, Santoshkumar Bhatted 3

7 EFFECTIVE AYURVEDIC MANAGEMENT FOR CALCANEAL SPUR –A CASE STUDY 160-163 Sawant Shreya Umesh1*, Jayant Subhash Hartalkar2, Sawant Umesh Vasant3

FUTURE EVENTS

8 CONFERENCES / SEMINARS / SYMPOSIA 164

Entire ISSUE – IJAAM- Vol:4/ Issue:3/ May – June - 2016

*****

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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE

IJAAM Vol: 4 / Issue: 3 / May – June – 2016 viii

INTENTIONALLY

KEPT

BLANK

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VOL 4

ISSUE 3 (2016) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE eISSN-2348-0173 pISSN-2395-3985

Shirke P.R. et.al. Study of Dhatupradoshaja Vikar w.s.r.t. Raktadhatupradoshaja Vikara: A Literery Review, Int. J. Ayu. Alt. Med., 2016; 4(3):116-122

Page

116

Page

116

REVIEW ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

STUDY OF DHATUPRADOSHAJA VIKAR W.S.R.T. RAKTADHATUPRADOSHAJA VIKARA: A LITERERY REVIEW

Prashant R. Shirke1*, Parag N. Deshmukhe2, Ravikumar B. Patil3, Milind C. Kirte4

Deepak P. Sawant5

1. Assistant Professor, Dept. of Samhita, Siddhant, Hon. Shri Annasaheb Dange Ayurved Medical

College Ashta, Ta.l Walwa. Dist. Sangli, Contact No. +919970708635, Email – [email protected]

2. Associate Professor, Dept. of Kayachikitsa, Hon. Shri Annasaheb Dange Ayurved Medical College Ashta, Tal. Walwa. Dist. Sangli, Contact No. +919423033159, Email – [email protected]

3. Assistant Professor, Dept. of Panchkarma, Hon. Shri Annasaheb Dange Ayurved Medical College,

Ashta, Tal., Walwa. Dist. Sangli, Contact No. +919822010316, Email – [email protected]

4. Assistant Professor, Dept. of Kriya Sharir, Government Ayurved College Vazirabad Nanded, Contact No. +918421866507, Email – [email protected]

5. Professor & HOD, Dept. of Shalakya Tantra, Government Ayurved College, Osmanabad, Contact

No. +919422436590, Email – [email protected]

Article Received on - 3rd July 2016 Article Revised on - 21st July 2016 Article Accepted on - 25th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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VOL 4

ISSUE 3 (2016) INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE eISSN-2348-0173 pISSN-2395-3985

Shirke P.R. et.al. Study of Dhatupradoshaja Vikar w.s.r.t. Raktadhatupradoshaja Vikara: A Literery Review, Int. J. Ayu. Alt. Med., 2016; 4(3):116-122

Page

117

Page

117

REVIEW ARTICLE *Corresponding Author Prashant R. Shirke Assistant Professor, Dept. of Samhita, Siddhant, Hon. Shri Annasaheb Dange Ayurved Medical College Ashta, Ta.l Walwa. Dist. Sangli, Contact No. +919970708635 Email – [email protected]

QR Code IJAAM

www.ijaam.org

ABSTRACT: Tridosha, saptadhatu and trimala are the root cause of the body. Harmony among

these three will lead to health and disturbances will cause the disease. Dhatus are the bearing pillars of the body. Dhatu bear the body to maintain the homeostasis.the body remains healthy till the doshas are prakrut. Once the dhatus get afflicted by the doshas the person gets diseased. Ahara and vihara are the causative factor for the formation of disease. Improper diet and habit leads to the vitiation of doshas. In ayurvedic classics the diseases as per vitiation of dhatus has been mentioned.Among the seven dhatus the dosha vitiate to which dhatu, the diseases occurs. Dhatu pradoshaja vikaras is a special clinical condition explained in ayurvedic classics. Here the diseases have been explained as per the affliction of doshas to dhatu. Rakta dhatu is also get afflicted by different diseases as per the vitiation of dosha. So in present literature review an effort has been made to understand the dhatupradoshaja vikara w.s.r. to raktadhatupradoshaja vikara.

Key Words: Dhatu, Pradoshaja vikara, Raktadhatupradoshaja

INTRODUCTION Evidence based medicine is the mantra of modern era, so revalidation and revitalization is essential through research in both fundamental and applied aspect of Ayurveda. When dhatus are in normal form- Prasanna Rupnormal form of dhatus affords to growth but on the contrary if impure form –Mala rupa forms are retained it behaves like toxins that irritate and damage the system. “Dhatu pradoshajatwa”– is a condition representing the extreme vitiated status of dhatus. Dalhana in his commentary mentioned the need behind explaining the Dhatu pradoshaja vikaras separately i.e. “Chikistavishesa vijnanartha” and “sukha Sadhyatvadi karma Bodhatham.” Hence it is very interesting to know whether these terms are only mirror image of Dhatu pradoshajatwa or represents a different status of Dhatu in the pathogenesis i.e., aim of this study is to extricate the hidden thoughts of our ancient acharyas behind this concept and to evaluate the role of Dhatu’ both in onset of disease and in the preservation of health by conceptual assessment. AIM & OBJECTIVES

1. To understand the dhatupradoshaja vikara w.s.r. to raktadhatupradoshaja vikara.

2. To study in detail the concept of Dhatu pradoshaja vikaras described in the classical Ayurvedic texts.

3. Conceptual assessment of rakta Dhatu pradoshaja vikaras.

MATERIALS & METHODS Materials: Charaka Samhita and its commentaries, Sushruta Samhita and its commentaries, Astanga Hridaya and its commentaries, Astanga Sanraha and its commentaries, Bhela Samhita, Sharangadhara Samhita, Yogaratnakara, Ayurveda ka Vaijnanika Itihasa, Ayurveda ka brihat Itihasa, Fundamentals of Ayurveda -M. Mahadeva Shastry, Introduction to Kaychikitsa - C. Dwarakanath, Basic Ayurvedic concepts - V. V. S. Shastry, Comprehensive Kaychikitsa and Principals of Ayurveda –Dr. M. Udupa, Sharira Kriya Vignana and Roga Vignana – Dr. P. S. Byadgi, Principals of Anatomy and Physiology- Tratora, Dericson, Churchill Livingstone, Medical Dictionary- Nancy Roper, Tabers- Medical Dictionary.

Methods Review of literature, analysing the collected matter and discussion is done. The conclusion has been drawn as per the analysed literature. Concept of Dhatu Parinamana Paka ortransformation is made possible by Jatharagni, Bhutagni, and Dhatvagni Pakas. When food enter in the body, they have to face several chemical changes in the presence of Jatharagni, Bhutagni and Dhatwagni,so, that they will changed into suitable form for absorption. This process is known as Ahara Paripaka.

STUDY OF DHATUPRADOSHAJA VIKAR W.S.R.T. RAKTADHATUPRADOSHAJA VIKARA: A LITERERY REVIEW

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Table No.1: Panchabhautic compositions of dhatus

Dhatu Guna Mahabhuta Rasa Sita, Snigdha,Mrdu,Dravata AP Dominant

Rakta Dravata, Sara, Arakta,Laghu, Usna, Visra AP dominant Teja

Mamsa Guru, Sthula, Sthira Prthvi Dominant Meda Mrdu,Guru, snigdha, Sthira, Sthula AP Dominant Vayu Asthi Khara, Guru, Sthula, Sthira, Ruksha Prthvi Dominant Vayu Majja Sita, Guru, Snigdha AP Dominant Sukra Sita, Drava, Snigdha AP Dominant

Dhatu Pradoshaja Vikara The term Dhatu Pradoshaja Vikara consists of three terms viz., dhatu, pradoshaja, vikara. Dhatu: D-Dhach= (Dharan,Poshan)

A dhatu is that entits which supports the body and also provides nourishment to the body.

Pradoshaja: Pra + Dosha + ja Pra: prakrushthena, utkarshe, arambha [1] Dictionary meanings: excessively, commencing, beginning [2]. Dosha: doshanam,dustam, papam[3] . Dictionary meanings: a fault, defect, sinfulness[,4]. Ja: janyatwat, janmati, janardane[ 5]. Dictionary meanings: born from, produced, caused by[6,7]. Vikara: The term ‘vikara’ is pulling pada. The vyutpatti of which as follows- Vi + kra + ghna vikara. The term vikara is derived from moolandhatu ‘kru’ with ‘vi’ upasarga and ‘ghna’ pratyaya [8]. Vikara: parinama, vikruti, vikriya[9]. Dushti means condition of deviation from normalcy (Swa Prakrti Vipareeta). Any change in the normal functioning of the Dhatu is due to the loss of equilibrium of the three Dohsas – Susruta explained that- What the Dhatus are extremely vitiated by the Dohsas then it called as “ Dhatu Pradoshaja Vikaras” Dhatu Pradoshaja Vyadhi is nothing but the group of symptoms exhibited due to vitiation of Dhatu by Dosha [10]. “Dalhana” in his

commentary mentioned the need behind explaining the Dhatu Pradoshaja Vikaras separately.

1. Chikitsa Vishesa Vijnanartha. 2. Sukhasadhyatvadi Karma Boodhartham.

These two things are very essential to know for a vaidya to avoid failure in his practice [11]. Chakrapani in his commentary on Vidhi Sonitiya Adhyaya distinctly revealed that in some cases only Dosha Viparita Chikitsa will not bring complete relief to the patient [12]. Chakrapani has used the term “Asraya Prabhava” to indicate the significance of Dhatu in the treatment. If thoroughly go on scanning the Ayurvedic texts only few of them has explained the diseases under the caption of Dhatu Pradoshaja Vikaras separately. [13] In Charaka Samhita in Vividha Sitapitiya Adhyaya the description of Dhatu Pradoshaja Vikaras and its Principle of Management is available. In total 80 are explained under the heading of Dhatu Pradoshaja Vikaras by Charaka. Sushruta has explained the Dhatu Pradoshaja Vikara in Vyadhisammudesiya chapter. In Sushruta total 71 Vyadhi is mentioned. He has only listed the names of Dhatu Pradoshaja Vikaras but not described the Principle of Management[14]. In Bhela Samhita Dhatu Vyapattijanya vikaras is the term used for Dhatu Pradoshaja Vikaras[15].

Table No. 2: Vyadhis mentioned by Samhitas under the heading of Dhatu Pradoshaja Vikaras

Dhatu Pradoshaja Vikaras Charaka[16] Sushruta[17] Bhela[18]

Rasa pradoshaja 18 16 13 Rakta Pradoshaja 18 18 07 Mamsa Pradoshaja 10 13 05 Meda Pradoshaja 15 07 06 Asthi Pradoshaja 07 05 03 Majja Pradoshaja 05 07 06 Sukra pradoshaja 07 05 06 80 71 46

Importance of Strotas in Relation to Dhatu Pradoshaja Vikaras: Healthy strotasas perform their normal functions as a result body is free from disease and unhealthy strotas become root cause for the development of pathogenesis19. Once the

empty spaces (strotas ) become abnormal, it brings abnormality in normal Dhatu by not transforting to required destination; this is because of the abnormality in strotas. Strotas vitiates other srotas, dhatus vitiates other dhatus;for all these

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happenings disturbed doshas are responsible. Due to their pervasion to entire body, they become responsible for aggravation as well as alleviation of doshas and responsible for vrudhi kshaya of Dhatu inside the body. Dhatugata – Dhatushita and Dhatu Asrta Condition[20]: “Gatatva”is one such complex phenomenon mentioned in all classical texts. Here first, Dosha. Vitiated by its pathogenesis, when involves some specific site i.e. Dhatu, Upadhatu or Asaya, then such condition is termed by adding adjectives of that site (Dhatu or Asaya) as Pakvasaya Gata Vata, Rakta Gata Vata etc. Panchabhautikatwam of Rakta Dhatu [21]: Every substance is made of five mahabhutas. Hence they are also present in the rakta Dhatu, and qualities of rakta Dhatu can be explained on the basis of five mahabhutas. In spite of existence of five- mahabhutas, rakta Dhatu has dominance of teja and jala mahabhuta. Rakta Swaroopa (Qualities): To explain colour of rakta Dhatu, it is compared with many red coloured substances that exist in nature. Hence blood which oozes from the body is red like red coloured insect (indragopa) which is seen mainly in rainy season, blackish red like lac, small bright red fruit ( like gunja) or yellowish’ orange red like gold. Red colour of gunja and lac has been compared with the colour of human blood, to study relationship between colour of skin and colour of blood. In darker skin persons the colour of blood is like lac, while in lighter skin persons the colour of blood is dark red. In Vata constitution, colour of skin is dark. In Pitta and Kapha constitution, the skin colour is from light to lair or white. Rakta Dhatu which supports the life is sweet, heavy, mobile and sweet in taste22. Raktavaha Srotas [22, 23, 24]: Yakrit and pleeha are stated to be the mulas of raktavaha strotases by Charaka and Sushruta added raktavahini dhamanis. Charaka has clearly stated that Hridaya (thoracic heart ) and ten dhamanis also are to be taken as rakta sthana, therefore these also to be considered as the mula of raktavah strotases. Importance of Rakta Dhatu [25] : Sushruta says that rakta Dhatu is a root of living body; it maintains life, so one should take proper care of rakta Dhatu by proper diet that gives nourishment to rakta and proper regimen. Rakta Dusti Nidana: The nidanas of rakta pradoshaja vikaras can be classified into samanya and vishesa nidana. These are follows-

Samanya nidana [26,27] : In Charaka Samhita and Astanga hrudaya, samanya nidanas are mentioned for all the Dhatu pradoshaja vikaras. They are;

A. Dosha guna Sama ahara and vihara B. Dhatu viguna ahara and vihara C. Rutu viguna ahara and vihara

Dosha guna Sama ahara and vihara: The intake of nidanas in the form of ahara and vihara which are having similar gunas to that of particular dosha gunas leads to dosha vruddhi by samanyam vruddhikaranam siddhant. e.g. if person consumes katu, amla, lavana rasayukta ahra sevana and vihara nidanas like diwaswapna, atyadana, ayapasevana, vegaavarodha etc, then there will be rakta vruddhi.

Dhatu viguna ahara and vihara: The intake of nidanas in the form of ahara and viahara which are having dissimilar gunas ti that of particular Dhatu gunas i.e. Dhatu virodhaka swabhava by vishesa siddhanta.

Rutu viguna ahara and vihara: The particular ahara and vihara which are dealt for each rutu if not followed leads to dosha vitiation i.e. vipareeta to Rutucharya palana.

Vishesa nidana[28]: In Charaka samhita some specific nidanas are mentioned for Rakta pradoshaja vikaras. These are—

a) Unwholesome, hot and sharp wine and food in large quantity;

b) Exceedingly saline, alkaline, acidic and pungent food;

c) Kuutha ( Dolichos biflorus ), masha ( Phaseolus radiates ) and til oil;

d) Pindula ( Dioscorea alata ), and all green eatables like radish, etc;

e) Meat of aquatic, marshy and prasaha types of animals and animals living in holes;

f) Curd, sour whey, vinegar, wine and sauviraka type of liquor;

g) Rotten, putrefied food articles and those having mutually contradictory qualities; And

h) Any other type of food in excessive quantity. Blood also gets vitiated by the following:-

1. Sleeping during day time after taking liquid, unctuous and heavy food;

2. Excessive anger, excessive exposure to the sun and fire;

3. Suppression of the urge for vomiting; 4. Absence of blood-letting therapy ( in the

autumn); 5. Exertion, external injury, heat, taking food

before the previous meal is digested; 6. By the very nature of the autumn season.

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Rakta Pradoshaja Vikaras: Kustha [29]Visarpa[30]Raktapitta[31] Pama[32] Vyanga – Nilika[33] Asragdara, Gulma[34] Kamala[35] Kotha[36]

Vidradhi[37] Pleecharoga[38] Pidaka[39] Tilakalaka Piplu Rakta Mandala[40] Principle of Management For Rakta Pradoshaja Vikaras: Charak enumerated,therapies like virechana, upavsa or raktavistravan indicated for the treatment of raktapitta. Raktapittaharikriya should be considered as separate treatment modality, along with upavasa, virechna, raktamokshana, Raktapittaharikriya indicate the shaman therapy for alleviation of pittadosha along with that the virechana and raktamokshna. Hence the principle management of rakta pradoshaja vikaras will be managed as virechana, upavasa, raktamokshana.[41] DISCUSSION Concept of Dhatu Parinamana: Manifestation of any disease depends upon the quality of Dhatu present in the body and the quality of Dhatu depends upon the nutrition, they drawing from Ahararasa. And, the knowledge of the time factor about the Dhatu parinamana is also useful in the diagnosis of a disease. The nourishment of the body depends upon the nutrition action of jatharagni. The derangement of jatharagni results into affliction while if the Shareera is endued with jathragni adequately lives long in a good health. The transformation of Ahara rasa into the respective dhatus takes place due to their respective Agni i.e. dhatvagni. Chakrapani used the term posaka Dhatu (asthayi Dhatu) for the nutrient part and posya Dhatu (sthayi Dhatu ) for the part which is being nourished, so in nutshell one can say that the conversion of asthayi Dhatu (posaka Dhatu) into sthayi Dhatu (posya Dhatu) takes place due to dhatvagni. This process is also known as suksma pachana. Dhatvagni plays another role in the manifestation of disease because Dhatuvaisamya i.e. Dhatu vruddi or Dhatu kshaya condition depends upon the nature of dhatvagni present in the body.

Dhatu Prdoshaja Vikaras:- To discuss these concept two headings gives complete orientation.

A) List of Dhatu pradoshaja vikaras on the basis of vyadhis.

B) Division of Dhatu pradoshaja vikaras on the basis of lakshanas and vyadhi.

In Chraka Samhita, total 80 vikaras are explained under the heading of Dhatu pradoshaja vikara. While Sushruta, total 71 vyadhis are mentioned as Dhatu pradoshaja vikaras in Asthanga Sangraha and Asthanga Hridaya. In Bhela samhita a different term is used for Dhatu pradoshaja vikaras i.e. Dhatu vyapattijanya vikaras In total 46 vyadhis are listed by Bhela. Difference Between Dhatugata And Dhatu Pradoshaja Avastha: Dhatugata condition of doshas occurs just before the sthanasamsraya condition of dosha, while pradoshaja condition is the bheda avastha of the vyadhi (prakruti vikruti bhutatva).

1. In dhatugata condition only one Dhatu is involved in the pathogenesis e.g.- raktagata vata, mamsagata vata. While in the pradoshaja condition multiple dhatus may involved in th pathogenesis ex: prameha pidaka.

2. In the dhatugata condition the dhatus are either in the state of kshaya while in case of Dhatu pradoshaja condition dhatus are either ksapita/vruddha.

3. In case of dhatugata condition – especially in the case of vata there may be avarana (obstraction) by the Dhatu ex: Rakta gata vata. In caase of Dhatu pradoshaja vikara, avarana condition may occur ex: prameha.

4. The dhatugata condition only etiological factors are of aggravating the dosha (swanidana prakopa).while in the Dhatu pradoshaja vikaras the etiological factors having two fold natures is of both dosha and Dhatu.

Table No.3: Comparative Analysis between Dhatugata Condition and Dhatu Pradoshaja Condition

Sr.No. Dhatugata Dhatu pradoshaja

1 Dhatugata condition occurs before Sthana samsraya avastha.

Dhatu pradoshaja is the vyakti and bheda Avastha of any disease.

2 Only one Dhatu is involved. Multiple dhatus may involve. 3 Dhatus are in the state of kshaya avastha. Dhatus may be in vrudhi or kshaya. 4 The etiological factors are of dosha. The etiological factors are of both Dhatu and Dosha.

5 The treatment recommended is only dosha for pacification of dosha.

The treatment recommended for both and Dhatu.

6 Asthi majja gata condition is said to be Untreatable.

Gambheera dhatugata avastha is said to Untreatable.

7 Dhatugatatva condition is not a Progressive one. Dhatu pradoshaja is a progressive Condition.

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The journey of dosha from etiological factors to sthanasamsraya can be taken as gatatva of dosha. While when the dosha get lodged at a particular

site the condition can be consider as the “sthitatva” of dosha.

Table No.4: Comparative study between Dhatu avrtatva and Dhatu pradoshaja

Sr.No. Dhatu avrtatva Dhatu pradoshaja

1 Dhatu avrtatva is not a progressive condition. Dhatu pradoshaja is a progressive condition.

2 In avarana condition dhatu vrudhi is oserved. In dhatu pradoshaja condition, there is either dhatu vrudhi or dhatu kshaya depends upon the etiological factors involved.

3 The etiological factors involved are of avaraka( dhatu).

The etiological factors involved of both avaraka(dhatu) and avrta(dosha).

4 The provocation of vata by the etiological factors other than its own.

The provocation of dosha by its own etiological factors.

5 In dhatu avrtatva condition there may be karma hani or karma vrudhi of dosha observed depending upon the type of avarana.

In dhatu pradoshaja condition there is always karma vrudhi of dosha.

6 Avarana condition is explained only for vata dosha.

All the doshas may involve in the dhatu pradoshaja a condition depending upon the types of etiological factors.

7 In dhatu avarana the line of treatment is to remove the obstruction.

In dhatu pradoshaja dosha shodhana and dhatu prasadana treatment is needed.

8 In avarana rasavrta vata condition is not explained.

In dhatu pradoshaja vikaras rasa pradoshaja vikaras are explained separately.

Rakta Pradoshaja Vikaras: It does not necessarily means disease manifested only at the skin level. During the manifestation of a disease, where there is vitiation of Rakta Pradoshaja Vikaras. If the vitiated Rakta is compared with normal Rakta, the change in the properties denotes the dominance of Dosha, which has vitiated it. Two types of changes are found in the properties of rakta one change is called Prakruti samavayajanya which is in accordance with the action of the dosha and the other is Vikruti Vishama samavajanya that which is not in accordance with the action of Dosha. The dosha vitiated Rakta dhatu while in circulation reaches at various sites in the body creating a verity of symptoms when it attacks the skin, the skin shows discolouration, eruption, pain, burning sensation, swelling, tenderness. All these things depend upon the intensity of the vitiation of Dosha and the reaction of Dushya to it which is technically called as Vyadhiksamatva. In Charaka Samhita, Rakta pradoshaja vikaras are explained at two places in the Sutrasthana itself i.e. in Vidhisonitiya Adhyaya and in Vividhasitapitiya Adhyaya. Sushruta listed the Rakta pradoshaja vikaras in Vyadhi sammidesiya chapter. Though Vagbhata has not mentioned the dhatu pradoshaja vikaras separately but still the diseases which are explained in Siravyadha Vidhi Adhyaya have close similarity with the diseases mentioned as Rakta pradoshaja vokaras by Charaka and Susruta. In Rakta Pradoshaja vikaras there are some diseases which are indirectly related with Rakta dhatu e.g. Agnimandya, Anga Gaurava, Aruci, Tandra etc. there is certain other Vyadhi in which the Rakta Dhatu is trickling out of body e.g.

Raktapitta, Asrgdara, Raktameha etc some diseases reflects themselves in the form of Tvak Vikaras e.g. Kotha, Pidaka, Charmadala etc. Principle Management of Rakta Pradoshaja Vikaras: The principle of management for Rakta pradoshaja vikaras is described by Charaka in Vidhisonitiya adhyaya. While comprises two meanings, first meaning may be that the raktapittahari Kriya is a uddesha while virechana upavasa and raktamokshana is said to be nirdesha in the other meaning the raktapitthari Kriya can be consider as a separate treatment modality for rakta pradoshaja vikaras. Gangadhara has used the term Anuvasana instead of Upavasa the reason may be that anuvasana therapy produces effect on the dhatus also as explained by Charaka. Ganagadhara further advised a definite sequence of the treatment for management of Rakta pradoshaja vikaras. According to Charaka those diseases which remains uncured by dosha viparitha chikitsa should treated by raktamokshana therapy. CONCLUSIONS There must be a definite involvement of dhatu both in onset of disease and in the preservation of health. Hence, normal state of dhatu provides an almost impenetrable shield against disease. Jatharagni, Bhutagni, Dhatvagni is one of the main stay in the nutrition of body tissue. Therefore, any imbalance at that level leads to disturb the physiology which leads to pradoshaja vikaras. In the living body the mulla of all dhatu is rasa dhatu like that shareera mula is rakta dhatu. Hence, Sushruta said rakta dhatu is a root of living body

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because of shareera dharana function rakta also representing prana. Sthanas of Rakta have either with the formation of rakta or serve as its reservoir or both. Yakrit and pleeha are the sthanas of Rakta can be very well being appreciated from both the points of view. Sushruta treats rakta on a par with the other three shareera doshas, especially with the pitta dosha. He has, therefore, described the prakopa of this dhatu also and in general he considers that the causes or factors which excite the rakta dhatu are the same as those which excite the pitta dosha and vice versa. REFERENCES

1. Raja Radha Kantha Deva, Shabda Kalpa Druma, Part 1St,3rd ed. Varanasi:The Chaukhambha Sanskrit Series Office,1967,p.275.

2. V.S. Apte, Sanskrit English Dictionary,Varanasi : Motilal Banarsidas,1968,p 350.

3. Raja Radha Kantha Deva,Shabda Kalpa Druma,Part 1St,3rd ed.Varanasi:The Chaukhambha Sanskrit Series Office,1967,p.753.

4. V.S. Apte, Sanskrit English Dictionary, Varanasi: Motilal Banarsidas,1968,p 261.

5. Taranath Tarkavachaspathy Bhattacharya, Vachaspathyam, Part5th, Varanasi, The Chaukhambha Sanskrit Series Office, 1969, p.372.

6. Ibid, p. 372. 7. Ibid, p. 372. 8. Taranath Tarkavachaspathy Bhattacharya,

Vachaspathyam, Part5th, Varanasi, The Chaukhambha Sanskrit Series Office, 1969, p.3793.

9. Raja Radha Kantha Deva,Shabda Kalpa Druma,Part 2Nd ,3Rd ed. Varanasi: The Chaukhambha Sanskrit Series Office,1967,p.372.

10. Prof.P.V.Sharma,Prof.K.R.Srikantha Murthy,Sushrut Samhita,Sutra Sthana,Varanasi: Chaukhambha Bharti Academy, Reprint-2004, p.256

11. R.K. Sharma, Bhagwan Dash, Charaka Samhita With Ayurved Dipika Commentary Of Chakrpanidatta,4th ed. Varanasi: Chaukhambha Sanskrit Series Office,1995,p.406.

12. Ibid, p.275. 13. Shri. Satyanarayana Shastri, Charaka Samhita,Reprint-

2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003,p.571-573.

14. Dr. K.H. Krishnamuthy,Bhela Samhita,1st ed. Varanasi: Chaukhambha Sanskrit Bhavan, 2000, p.295.

15. Shri.Satyanarayana Shastri,Charaka Samhita,Reprint-2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003,p.571.

16. Prof. K. R. Srikantha Murthy, Sushrut Samhita, Reprint 2000.Varanasi: Chaukhambha Bharti Academy, Reprint-2000, p.256.

17. Dr.K.H.Krishnamuthy,Bhela Samhita,1st ed. Varanasi: Chaukhambha Sanskrit Bhavan,2000,p.295.

18. Shri.Satyanarayana Shastri,Charaka Samhita,Reprint-2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003,p.710.

19. Prof. K.R. Srikantha Murthy, Ashtang Sangraha, 1st ed., Varanasi, Chaukhambha Orientalia,2000,p.361-362.

20. Ibid, p.88. 21. Pandit Parshuram Shastri, Vidyasagar, Anonymous

Adhamalla Dipika And Gudarth Dipika Sanskrit Commentary, 3rd ed.,Varanasi: Chaukhambha Orientalia,1983,p.253.

22. Shri. Satyanarayana Shastri, Charaka Samhita,Reprint-2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003, p.711.

23. Prof. K.R. Srikantha Murthy,Sushrut Samhita, Reprint 2000.Varanasi: Chaukhambha Bharti Academy, Reprint-2000, p.391.

24. R.K. Sharma, Bhagwan Dash, Charaka Samhita with Ayurved Dipika Commentary of Chakrapanidatta, Varanasi: Chaukhambha Sanskrit Series Office, Reprint-2005, p.391.

25. Prof. K.R. Srikantha Murthy, Sushrut Samhita, Reprint 2000.Varanasi: Chaukhambha Bharti Academy, Reprint-2000, p.201.

26. Acharya Y.T., Charaka Samhita Of Agnivesha, 5th ed.,Varanasi: Chaukhamba Prakashan, 2007, p.252.

27. Yogindra Nath Sen Charaka Samhita Of Charaka,2Nd Vol.Banaras Chaukhamba Sanskrit Series Office,1922,p.989.

28. R.K. Sharma,Bhagwan Dash, Charaka Samhita With Ayurved Dipika Commentary Of Chakrpanidatta, Varanasi: Chaukhambha Sanskrit Series Office, Reprint-2005,p.403-405.

29. Ibid, p.125-127. 30. Ibid, p.342-343. 31. Ibid, p.86-88. 32. Ibid, p.127. 33. Prof. P.V. Sharma, Charaka Samhita, Chikitsa Sthana, 4th

ed, Varanasi: Chaukhambha Orientalia, Reprint-1998, p.376.

34. Ibid, p.98-100. 35. Ibid, p.275. 36. Ibid, p.275. 37. Dr. Mahesh Udupa, comprehensive Kayachikitsa, 1st ed.

Banglore, Laveena Publication,2004, p.1416. 38. Shri. Satyanarayana Shastri,Charaka Samhita,Reprint-

2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003,p.358-359.

39. Prof. P.V. Sharma, Charaka Samhita, Chikitsa Sthana,4th ed, Varanasi: Chaukhambha Orientalia, Reprint-1998,p.207.

40. Ibid, p.376. 41. Shri. Satyanarayana Shastri, Charaka Samhita,Reprint-

2003,Varanasi: Chaukhambha Bharti Academy, Reprint-2003,p.403

CITE THIS ARTICLE AS – Shirke P.R. et.al. Study of Dhatupradoshaja Vikar w.s.r.t. Raktadhatupradoshaja Vikara: A Literery Review, Int. J. Ayu. Alt. Med., 2016; 4(3):116-122 Source of Support – Nil Conflict of Interest – None Declared

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RESEARCH ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

ROLE OF KSHARSUTRA (PREPARED ACCORDING TO RASATARANGINI) IN BHAGANDARA WITH SPECIAL REFERENCE TO

FISTULA-IN-ANO

Ukhalkar V. P.1*, Pradnya Morwadkar (Vedika V. Bhoir) 2

1. Professor, Dept. of Shalya Tantra, Government Ayurved College, Vazirabad, Nanded Maharashtra, India, Contact No. +91 7755921987, Email- [email protected]

2. Assistant Professor, Dept. of Shalya Tantra, D. Y. Patil University School of Ayurveda, Nerul, Navi Mumbai, Contact No. +91 9029112333, Email - [email protected]

Article Received on - 2nd July 2016 Article Revised on - 18th July 2016 Article Accepted on - 25th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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RESEARCH ARTICLE *Corresponding Author Ukhalkar V. P. Professor, Dept. of Shalya Tantra, Government Ayurved College, Vazirabad, Nanded Maharashtra, India, Contact No. +91 7755921987, Email- [email protected]

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ABSTRACT: This paper reports about results of a prospective, randomized, control single blind

trial to evaluate the efficacy of Ksharsutra (prepared according to Rasatarangini) in Bhagandara with special reference to fistula-in-ano with control of Ksharsutra (prepared by standard method). Trial group having 30 patients was treated with application of Ksharsutra having 7 coatings (without apamarga kshar) & Control group with 30 patients was treated with the application of Ksharsutra having 21 coatings. The incidence of fistula was more common 43.33% in the age group 31-45 years, more in males 83.33%. The rate of cutting and healing of fistulous tract by using Ksharsutra having 7 coatings (prepared according to Rasatarangini) (i.e. Trial group) was found to be effective to cut the fistula in ano tract, gives more relief from pain and to heal wound after cutting of fistula in ano tract.

Key Words: Bhagandara, Kshara, Ksharasutra, Fistula in ano

INTRODUCTION Fistula-in-ano has been known to mankind as one of the commonest disastrous ano-rectal disease. The number of patients of fistula-in-ano attending surgical out patients department of an Ayurved hospital is again considerably high and increasing as well. The causative factor behind this is constipation, unhygienic ano-rectal region and today’s jet age life style. It’s a tract lined by granulation tissue, which connects deeply in the anal canal or rectum and superficially on the skin around the anus. The most common treatment in modern science for anal fistula includes surgical and para-surgical interventions. Surgical-Fistulectomy, Endorectal advancement flap, Surgisis bio-design anal fistula plug are most common and in Para-Surgical-Seton application, Fibrin glue etc. procedures are included. But fistula is still remaining a challenge to modern surgery due to its complications such as post operative incontinence, high recurrence rate and limitations including long term hospitalization and painful dressing. To the extent of management of fistula-in-ano by Ayurvedic way, Ksharsutra is the time tested and truly effective treatment. History of Ksharsutra in the management of Bhagandara [1] dates back to the time of Sushrut but as we trace back in texts almost all the scholars had mentioned the work on Ksharsutra in their treatises, but it is worth surprising to note absence of proper methodology of Ksharsutra preparation in Brihatatrayees. Chakrapani has given the reference of Ksharsutra in Chakradatta. [2] Later references are found in Rasachikista Vimarsh and

Bhavaprakash [3] about Ksharsutra preparation but idea was clearly explained by Rasatarangini. [4] Author has described about how to do the coating over thread, how many coatings to be done. The author is very particular in naming it as a Ksharsutra having 7 coatings prepared according to Rasatarangini, which is devoid of any Kshar. As per standard Ksharsutra concerned Late P. J. Deshpande Sir, (at Faculty of Ayurveda I.M.S. B.H.U. Varanasi) had revalidated and scientifically established the Ksharsutra technique for the treatment of fistula in ano. [5] He used Ksharsutra having 21 coatings with Apamarga Kshar in the management of fistula-in-ano and proved it best. Hence it was taken as the intervention for Control group. Sadanand Sharma quoted main and basic reference for preparation of Ksharsutra in which no Kshar was used for its preparation. So an attempt was made to rule out efficacy of Ksharsutra especially as mentioned in ‘Rasatarangini’. Objective: To evaluate the efficacy of cutting and healing rates with the use of Ksharsutra prepared according to text Rasatarangini in Bhagandara w. s. r. to Fistula-in-ano Materials:

1. Ksharsutra prepared according to reference mentioned in text Rasatarangini

2. Ksharsutra prepared according to standard method. (Standard Ksharsutra concerned with

ROLE OF KSHARSUTRA (PREPARED ACCORDING TO RASATARANGINI) IN BHAGANDARA WITH SPECIAL REFERENCE TO FISTULA-IN-ANO

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Late Dr. P. J. Deshpande, at faculty of Ayurveda I.M.S. B.H.U. Varanasi)

Preparation of Kshar and Ksharsutra Method of preparation of Kshar [6]: Apamarga (Achyranthus aspera linn) had been the plant used for deriving Kshar. The whole plant including its root, stems, leaves and seeds were used. Fruits were collected and were allowed to dry in a shade. When completely dry the plant was placed on a clean platform situated in a semi closed space i.e. place which was open but doesn’t permit entry to direct wind blasts. When it was fully burnt then ashes were allowed to cool and collect into the large pot. These ashes dissolved in six times of a clean tap water and thoroughly mixed. It was then being allowed to settle down and finally the supernatant fluid was collected in a separate pot. The residual ashes were again mixed with four times of water and the same procedure was repeated twice in order to take away all the alkaline materials from the ashes. Ultimately the ash remained as a neutral residue which was thrown. The fluid thus collected was filtered drop by drop through a double Whatman filter paper into a clean glass bottle. The filtrate thus received was clean, light brown and free from any suspended impurity. This liquid was kept in a pot of wide mouth and was slowly evaporated on a moderate flame. It was stirred from time to time by a flat stirrer of stainless steel. When the liquid starts becoming pasty or thick the flame was reduced and the solution was vigorously and effectively stirred after stabilizing the pot with the other hand using a forceps or a holder. If this care is not taken, the Kshar is likely to get burnt and stuck at the bottom of the pot. It was desirable to put off the flame when the liquid becomes a thick paste and it was allowed to dry while cooling down by continuous stir. The powder which remains at the end of process was white and coarse having flexed of different sizes. Preparation of Ksharsutra: Material used for Trial Group (i.e. Ksharsutra prepared according to Rasatarangini) [4] Linen Barbour No. 20 Snuhi ksheer (i.e. latex of Euphoria nerifolia) Turmeric powder (i.e. Powder of Curcuma

longa) Author mentioned thin but strong thread so linen Barbour 20 was used. Author mentioned to smear thread with fine powder of turmeric and snuhiksheer and dried in shadow. So linen barbour was smeared with mixture of fine powder of

turmeric and snuhiksheer and dried in Ksharsutra cabinet provided with U-V rays. Procedure was done with followings steps. It was speeded throughout the length and

breadth of the hanger which was then mounted over a hanger stand.

Each thread on the hanger was then smeared with latex i.e. snuhiksheer and fine powder of turmeric with the help of gauze piece soaked in mixture of above contains from all the four sides of threads.

The hanger replaced into the cabinet. The cabinet was device hot blower for drying the threads and an ultraviolet light for sterilization.

This procedure repeated for seven times. In the last after completely drying the threads

were cut from hanger and sealed in the air tight test tubes.

Material used for control Group (i.e. Ksharsutra prepared according to Standard method) [5]

Linen Barbour No. 20 Apamarga Kshar (i.e. water soluble ash

extract of Acaranthus aspera) Snuhi ksheer (i.e. latex of Euphoria nerifolia) Turmeric powder (i.e. Powder of Curcuma

longa) Method: The surgical lines thread of the size 20 was

speeded throughout the length and breadth of the hanger which was the mounted over a hanger stand.

Each thread on the hanger was then smeared with latex i.e. snuhiksheer with help of gauze piece.

The hanger replaced into the cabinet, the cabinet was provided with a device hot blower for drying the threads an ultraviolet light for sterilization.

This procedure repeated for 11 days. On the 12th day, the thread was again smeared with snuhi latex, then in the wet condition, the thread was spread over with Apamarga Kshar powder.

After all seven coating of Kshar the hanger gently shaken so that all the excess particles of Kshar fall down.

At 19th day, the dried thread was smeared again with latex and in wet condition, Turmeric powder was, spread over thread. The process was repeated for 3 consecutive days.

After that the ultraviolet lamp which was already fitted in the cabinet was lighted for

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20-30 minutes every day in order to have good sterilization of the threads.

In the last, after complete drying, each thread was cut measuring about 10-11 inches from hanger and sealed in glass tube or polythene pack.

Table 1: Order and numbers of coatings is divided in

present study

No. of coatings / Dravya

7 coating of Ksharasutra

21 coating of Ksharasutra

Snuhi - 11 Snuhi + Kshara - 7 Snuhi + Turmeric 7 3

Standardization of Ksharsutra: The prepared Ksharsutra was analysed for its tensile strength and diameter. The results obtained are as follows –

Table 2: Analytical reports of Ksharsutra

7 coating of Ksharasutra

21 coating of Ksharasutra

Tensile strength 10 kg 9 kg Diameter of Ksharsutra 0.068 cm 0.082 cm

Clinical Trial: Study Period: 2009 to 2012 Study, Place: Government Ayurved College and Hospital, Nanded. This was prospective, randomized, control single blind clinical trial. They were randomly divided into two groups for further study. Institutional ethics committee approval and regulatory compliance: Before the initiation ofthe study, the study protocol and related documents were reviewed and approved by Institutional Ethics Committee at GAC, Nanded. The study was conducted in accordance with Schedule Y of Drugs and Cosmetics act, India, amended in 2005 and ICMR ethical guidelines for biomedical research on human participants 2006. IEC Clearance No -GACN/VV/D-3/IEC/1995-2001/2010 Dated: 30/03/2010 The study had been carried out in following steps: A total 60 patients of fistula were randomly selected for the study which includes trial group and control group. Trial Group In this group all 30 patients had been treated with application of Ksharsutra having 7 coatings (prepared according to Rasatarangini)

Control Group In this group all 30 patients had been treated with the application of Ksharsutra having 21 coatings (prepared according to standard method). Inclusion Criteria

1. All patients of fistula in ano of age between 18 to 60 years.

2. Patients having low level fistula in ano. Exclusion Criteria

1. Patients of tuberculosis, actinomycosis, and diabetes mellitus.

2. Patients having life threatening systemic disease e.g. Malignancy.

3. Patients having pregnancy and lactation. 4. Patients with multiple fistulas in ano. 5. Patients with fistulous tract having

connection with other viscera like urinary bladder.

Withdrawal Criteria

1. Occurrence of serious adverse effect regarding given treatment.

2. The investigator feels that the protocol has been violated / Patient has become uncooperative.

Informed consent: Informed written consent from all participants was taken according to protocol. Clinical Examinations Thorough history of the complaints of the patients had been taken in their chronological order. Each and every patient had been carefully examined clinically for general systemic and local examination. Local Examination: After taking prior consent, either lithotomy or left lateral position was given to the patients under proper illumination. Local examination i.e. per rectal examination had been carried out and points were noted as below. Inspection

Position of the external opening. Probable position of the internal opening

according to Goodsall’s rule Discharge from the external opening i.e.

Pus/ Pus with blood / Blood / Serous / Faecal matter / gas.

Per rectal discharge i.e. pus / pus with blood / blood / serous / mucus.

Palpation Local Temperature. Tenderness. Fluctuation and area of induration

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Fibrous fistulous tract and its course. Per rectal digital examination

Tone of Sphincters. Signs of inflammation. Feeling of internal opening.

Proctoscopy

Signs of Inflammation. Internal haemorrhoids or any growth. Internal opening of fistula in ano.

Laboratory Investigations 1. Fistulogram – if needed. 2. Blood- Haemoglobin (%), Bleeding Time,

Clotting Time, Total Leucocytes count, Different Leucocytes count, Random Blood Sugar Level, HIV I & II.

3. Urine- Albumin, Sugar, Microscopic. Application of Ksharsutra Instrument used for Ksharsutra application

1. Probe. 2. Mosquito Artery Forceps. 3. Stitch Remove Scissor. 4. Straight Artery foreceps. 5. Cotton Pad. 6. Dettol Swab 7. 2cc/ 5 cc dispo syringe. 8. Xylocaine Jelly 2%.

Method for application of thread (Ksharsutra): Fitness for procedure and for anaesthesia had been taken from Physician and anaesthetist. Ksharsutra application procedure had been carried out under appropriate anaesthesia if needed. This procedure had been carried out in Operation Theatre. Pre procedure: For application of the thread the patient had been placed in lithotomy position and the perineum was cleaned with antiseptic lotion and draped with sterile towel. A tray containing sterilized instrument including specially designed probe of different sizes. Procedure: The index finger of the hand was gently introduced into the anus and the inner opening of fistula was located. The selected probe had been passed through external opening of tract

and slowly pushed in the direction of least resistance. The tip of probe had been guided by the finger in the anus in order to avoid formation false passage. The probe then guided into the anal canal through the internal opening of the tract and finally brought out of the anal aperture by rotating the handle of probe slightly. A fresh and sterilized thread from the sealed tube threaded through the projection of eye, and probe pulled out, thus leaving thread in fistulous tract. The two ends of the thread had been tied outside the anal orifice firmly. Post Procedure: It had been advised to take a simple diet and adjust bowel movement by mild laxative. It had been advised to take sitz bath for 10-15 minutes every day. Change of thread and its measurement: This had been carried out in minor O. T. On the day of probing simple thread ligated into the fistulous tract upto 3 days. After 3 days Ksharsutra ligated to simple thread and the simple thread made to move in circular movement up to tied Ksharsutra, when it came from another end of the tract holding the Ksharsutra. The old, simple thread had been cut and taken out. The thread end to end had been measured. Similar method had been carried out during every change of Ksharsutra (i.e. after 7 days). Procedure had been continued till the tract was cut through. Follow Up Follow up of patients of two groups were

taken weekly up to 12 weeks or up to cut through which ever occurred earlier.

Observational parameters: Length of the thread; discharge and pain were recorded at each and every follow up and unit cutting time and unit healing cutting time was taken at the end of treatment.

The record had been maintained in the form of Case Record Form.

Observational parameters: Length: Length of the thread is recorded in centimetres at each and every follow up and is considered as the length of the tract.

a) Unit cutting time of fistula in ano

(day/cm) = Total no. of days for complete cutting of tract Initial length of Tract (thread)

b) Unit healing time of fistula in ano

(day/cm) = Total no. of days for compete healing of tract Initial length of Tract (thread)

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Discharge: Discharge from the fistula is recorded in the form of

No Discharge 0 Mild Discharge single pad is sufficient per day +

Moderate discharge two to three pads are necessary per day ++ Profuse discharge more than three pads are necessary per day +++

[The pads major three inches by three inches by one centimetre (thickness)]

Pain:

No pain 0 Pain felt by patient only at the time changing the Ksharsutra. +

Pain lasts for two hours after changing the the Ksharsutra. ++ Pain lasts for 24 hours or more than 24 hours after changing the

Ksharsutra. +++

Criteria for cure:

1. Cured: fistulous tract is completely cut through and healed.

2. Relieved: fistulous tract is incompletely cut or completely cut through and healing in process.

3. Not cured: Sign and symptoms not relieved no cutting no healing.

Statistical Analysis To assess the results of the study both, objective parameter (i.e. time required for complete cutting and healing of 1 cm of fistulous tract) and the subjective (i.e. discharge and pain) parameters were recorded before the commencement of treatment, at each and every follow up and completion of treatment. The level of significance

was set at 5% (p=0.05). As the sample size was small Student’s‘t’ test was applied to know the significance of objective and subjective parameters. Unpaired‘t’ test was applied to compare the objective parameters (i.e. time required for complete cutting and healing of 1 cm of fistulous tract) of Trial Group and Control Group. Paired‘t’ test was applied to assess the subjective parameters (i.e. discharge and pain of Trial group and control group). To apply statistics conveniently, the symptoms discharge and pain, on the day of commencement (0 day) and 12th follow up, were taken into consideration. RESULTS Effect of Ksharsutra on Length of tract of Fistula

Table 3: Length of tract of Ksharsutra in Trial group, (Paired ‘t’ test is applied)

Follow up Weeks 0-4th 4-8th 8-12th 0-12th

Mean (cm) 2.42 1.752 0.89 5.04 SD 1.05 0.68 1.02 1.46 SE 0.19 0.12 0.18 0.26 T 12.61 13.82 4.77 18.90 P P<0.05 P<0.05 P<0.05 P<0.05

ttable 2.05 2.05 2.05 2.05

Table 4: Effect of treatment on length of tract of Ksharsutra in Control Group. (Paired ‘t’ test is applied)

Follow up Weeks 0-4th 4-8th 8-12th 0-12th

Mean (cm) 1.95 1.28 0.58 3.81 SD 0.72 0.73 0.70 1.26 SE 0.13 0.13 0.12 0.23 T 14.76 9.63 4.49 16.46 P P<0.05 P<0.05 P<0.05 P<0.05 ttable 2.05 2.05 2.05 2.05

The above table suggests that the difference in length of tract of Ksharsutra between two consecutive follow-ups as well as before and after treatment was significant in both groups.

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Table 5: Comparison Ksharsutra on length of tract in Trial group and Control group (unpaired ‘t’ test applied)

Groups Mean S.D. S.E. tcal. P ttable T-C 1.22 1.36 0.35 3.47 P<0.05 2.05

When both groups were compared for Length of tract of Ksharsutra, it was found that, Trial group treatment was significant than control group treatment.

Fig 1: Difference between mean length of tract cutting during study

Table 6: Number of patients had been completely cut through of fistulous tract in weeks during study

Complete cut through of fistulous tract (wks)

Trial Group Control Group

Mean of initial length (cm) No of Patients Mean of initial

length (cm) No of Patients

3-8 4.13 15 3.00 14 8-13 5.85 7 4.15 8 13-18 6.11 8 5.92 7 18-23 0 0 0 0 23-28 0 0 10 1

Above Table showing number of patients had been completely cut through of fistulous tract in weeks during study Effect of Ksharsutra on discharge from tract of Fistula

Table 7: Effect of therapy on Discharge in Trial group

Mean S.D. S.E. t P ttable BT-AT 2.1 0.55 0.1 21 P<0.05 2.05

[BT- Before Treatment, AT- After Treatment] In Trial group value of tcalculated was more than ttable. So the effect of therapy was significant on Discharge.

Table 8: Effect of therapy on Discharge in Control group

Mean S.D. S.E. t P ttable BT-AT 1.77 0.43 0.07 22.49 P<0.05 2.05

[BT- Before Treatment, AT- After Treatment] In Control group value of tcalculated was more than ttable. So the effect of therapy was significant on Discharge.

Table 9: Comparison between Ksharsutra in Trial group and Control group on Discharge (‘unpaired ‘t’ test).

Mean S.D. S.E. t P ttable

T-C 0.33 0.49 0.13 2.62 P<0.05 2.05 [T- Treatment Group, C- Control Group]

study.

5.33

2.9

1.18

0.29

4.28

2.33

1.04 0.46

0

1

2

3

4

5

6

0th 4th 8th 12th

Weeks

Mea

n le

nth

of tr

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Trial group Control group

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The difference was statistically significant at the level of 5% significant. Trial group (i.e. made according to Rasatarangini) was best tratment of fistula in ano for reduction of discharge. Effect of Ksharsutra on discharge from tract of Fistula

Table 10: Effect of therapy on Pain in Trial group

Mean S.D. S.E. t P ttable BT-AT 2.27 0.64 0.11 19.40 P<0.05 2.05

[BT- Before Treatment, AT- After Treatment] In Trial group value of tcalculated was more than ttable. So the effect of therapy was significant on Pain.

Table 11: Effect of therapy on Pain in Control group

Mean S.D. S.E. t P ttable BT-AT 1.5 0.50 0.09 16.15 P<0.05 2.05

[BT- Before Treatment, AT- After Treatment] In Control group value of tcalculated was more than ttable. So the effect of therapy was significant on Pain.

Table 12: Comparison between Ksharsutra in Trial group and control group on Pain (‘unpaired ‘t’ test)

Mean S.D. S.E. t P ttable T-C 0.76 0.57 0.14 5.14 P<0.05 2.05

[T- Treatment Group, C- Control Group] The difference was statistically significant at the level of 5% significant. Trial group (i.e. made according to Rasatarangini) was best treatment of fistula in ano for reduction of pain. Effect of Ksharsutra on unit cutting time from tract of Fistula

Table 13: Comparison between two different coating Ksharsutra for unit cutting time of fistulous tract

Group Mean 1 SD 1 Mean 2 SD 2 SE t P T-C 12.14 2.90 15.75 3.80 0.87 4.14 P <0.05

[T- Treatment Group, C- Control Group] The difference was statistically significant at the level of 5% significant. Trial group (i.e. made according to Rasatarangini) was significant in unit cutting time.

Effect of Ksharsutra on unit healing time from tract of Fistula

Table 14: Comparison between two different coatings of Ksharsutra for unit healing time of fistulous tract

Group Mean 1 SD 1 Mean 2 SD 2 SE T p T-C 13.99 2.75 17.78 4.13 0.90 4.17 P <0.05

[T- Treatment Group, C- Control Group] The difference was statistically significant at the level of 5% significant. Trial group (i.e. made according to Rasatarangini) was significant in unit healing time.

Table 15: Overall assessment of therapy

Improvement Trial group Control group Cured 21 (70.00%) 19 (63.33%) Relieved 09 (30.00%) 11 (36.66%) Not cured 0.00 0.00 Total 30 (100) 30 (100)

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Fig 2: Overall assessment of Therapy

The above table & Figure shows that the result obtained in trial group were best i.e. more number of patients were cured and all other relieved. DISCUSSION The efficacy of the Khsarsutra prepared according to Rasatarangini in the management of low level fistula in ano had been dealt in present study. A total 60 patients of fistula were randomly selected for the study which includes trial group and control group. The patients in the trial group were treated with Ksharsutra having 7 coating (according to Rasatarangni). The patients in the control group were treated with Kshar-sutra having 21 coating. The observational parameters i.e. length of fistulous tract, discharge and pain were recorded at weekly intervals up to the complete cutting and healing of the fistulous tract. The characteristic features observed during the study were as following The incidence of fistula was more common

43.33% in the age group 31-45 years, while it was less common 23.33% in the age group 46-60 years. However, fistula is a disease of the middle age.

The incidence of fistula was more in males 83.33% whereas considerably less in females 11.66%. This may be attributed to, the no. and the size of the anal glands which are greater in males over females. It was also recorded that incidence of fistula having non vegetarian diet was much more, as 53.33% of the patients were having mixed diet, while 46.67% of the patients consumed vegetarian diet. As diet was considered it was found that the persons which consume non-vegetarian and spicy diet irregularly more suffering from fistula in ano because it may be due to this type of diet producing constipation and other

ano-rectal disorders forming infection of anal glands and resulting into fistula formation.

The bowel habit of 55% of the patients was regular whereas it was found to be irregular in 45% of the patients.

The nature of work of 50% of the patients was sedentary, while it was non-sedentary in 50% patients.

The characteristic features observed in relation to the statistical analysis of the observational parameter were- Length: The mean time required for complete cutting of 1 cm of fistulous tract was found 12.14 days in trial group (i.e. Ksharsutra according to Rasatarangini), in control group it was found 15.75 days (i.e. Ksharsutra having 21 coatings).The mean time required for complete healing of 1 cm of fistulous tract was found 13.99 days in trial group (i.e. Ksharsutra according to Rasataragini), in control group it was found 17.78 days (i.e. Ksharsutra having 21 coatings). By the application of paired‘t’ test to trial group, control group, it were found that these groups are statistically significant and hence comparable. Cutting of length is directly proportional to tensile strength. 7 coating Ksharsutra prepared according to Rasatarangini had more tensile strength than standard Ksharsutra. Hence it may be cause for fast cutting of fistulous tract in trial group than control group. Sufficient discharge after the change of thread explains the proper drainage of the abscess cavity and thereby in turns helps healing of the tract with fresh granulation tissue. Another observation made during the treatment of good healing in spite of the irritating property of the presence of thread as a foreign body this can be explained in the light of one concept that irritation promotes healing. Turmeric can promote healing process as well as it acts as antiseptic and

2119

911

0 00

5

10

15

20

25

No.

of Pa

tient

s

Cured Relieved Not curedImprovement

Over all assessment of therapy

Trial group Control group

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Ukhalkar V. P., Morwadkar P., Role of Ksharsutra (Prepared According to Rasatarangini) in Bhagandara with Special Reference to Fistula-In-Ano, Int. J. Ayu. Alt. Med., 2016; 4(3):123-132

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antihistaminic property. [7] Ksharsutra having 7 coatings more Turmeric coating which promotes fast healing than Ksharsutra having 21 coating respectively. Kshar powder was excessively hygroscopic which catches moisture and becomes useless if left exposed to the atmospheric air. [8] Discharge: From statistical analysis it was found that trial group (i.e. Ksharsutra prepared according to Rasatarangini) was more effective in reduction of discharge than that of the Ksharsutra having 21 coatings. Quantity of discharge is inversely proportional to healing of fistulous tract. Effective reduction in discharge in patients of trial group (i.e. Ksharsutra prepared according to Rasatarangini) may be contributed to more healing of the tract than control group i.e. Ksharsutra having 21 coatings. Moreover, more healing and hence, less discharge may be due to the antimicrobial activity of turmeric. [7] Pain: From statistical analysis it was found that trial group (i.e. Ksharsutra prepared according to Rasatarangini) was more effective and gives more relief from pain as that of the Ksharsutra having 21 coatings. Significant reduction of pain in trial group (i.e. Ksharsutra prepared according to Rasatarangini) may be contributed to more number of coatings of Turmeric which directly come in contact with wound than the Ksharsutra having 21 coating which is coated with 7 coating of snuhi + Kshara after 11 coating of snuhi followed by 3 coating of snuhi + tumeric. Evidences are present showing anti-nioceptive (pain relieving agent) effect of curcumin present in Turmeric. [9]

Also it was thought to be a natural inhibitor of cox2 enzyme. Scope for further study: Physiochemical analysis of Ksharsutra having 7 coatings and 21 coatings should be carried out. Further study to evaluate

relation between tensile strength and cutting ratio of Ksharsutra in fistula-in-ano should be carried out. CONCLUSION The rate of cutting and healing of fistulous tract by using Ksharsutra having 7 coatings according to Rasatarangini (i.e. Trial group) was found to be significantly higher than Ksharsutra having 21 coatings (i.e. Control group). This clearly suggests that the duration of treatment of the fistula was considerably reduced by the use of 7 coatings of Ksharsutra according to Rasatarangini for Bhagandara (fistula in ano). Hence it was found that Ksharsutra having 7 coatings according to Rasatarangini is effective and the best for the treatment of Bhagandara. (Fistula in ano) REFERENCES

1. Trikamji YT, editor, Sushrut Samhita, Reprint, Nibandhasangraha Sanskrit commentary, Chaukhamba Surabharati Publications, Varanasi, 1994, p. 351

2. Chakrapani Datta; Bhagandara Adhikara; Chakradatta, 2nd Edition, Sri Laxmi Venkateshwara steam press, Mumbai, 1959, p. 206-208.

3. Mishra B., editor, Bhavaprakash, 7th ed. Vidyotini hindi commentary, Chaukhambha Sanskrit Sansthan, Varanasi, 2000, p.500-506.

4. Sharma S. Rasatarangini, Hindi commentary, Reprint, Motilal Banarasidas Publication, Delhi, India, 2004, p. 527-30.

5. K. H. H. V. S. S. Narasimha Murthy. Prof P J Deshpande – Reinventer of Kshar Sutra Therapy. AAM. 2012; 1(4): 173-175.

6. Sharma S. Rasatarangini, Hindi commentary, Reprint, Motilal Banarasidas Publication, Delhi, India, 2004, p. 337.

7. Krup V, Prakash LH, Harini A (2013) Pharmacological Activities of Turmeric (Curcuma longa linn): A Review. J Homeop Ayurv Med 2:133.

8. http://ksharasutraindia.blogspot.in/2014_09_01_archive.html [Accessed date 14.08.2016]

9. Sharma S, Kulkarni S.K., Agrewala J.N., Choprak’Curcumin attenuates thermal hyperalagesia in a diabetic mouse model of neuropathic pain’ EUR.J.pharmacol.2006 may 1,J 36(3),256-6.

CITE THIS ARTICLE AS – Ukhalkar V. P., Morwadkar P., Role of Ksharsutra (Prepared According to Rasatarangini) in Bhagandara with Special Reference to Fistula-In-Ano, Int. J. Ayu. Alt. Med., 2016; 4(3):123-132 Source of Support – Nil Conflict of Interest – None Declared

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Ranjna Chawla et.al., Effect of Different Intervals of Yoga and Naturopathy Treatments on Disease Activity Score, Symptom Score, Rheumatoid Factor, Uric Acid and Kidney Function Tests in Patients Suffering from Rheumatoid Arthritis, Int. J. Ayu. Alt. Med., 2016;

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RESEARCH ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

EFFECT OF DIFFERENT INTERVALS OF YOGA AND NATUROPATHY TREATMENTS ON DISEASE ACTIVITY SCORE, SYMPTOM SCORE,

RHEUMATOID FACTOR, URIC ACID AND KIDNEY FUNCTION TESTS IN PATIENTS SUFFERING FROM RHEUMATOID ARTHRITIS

Ranjna Chawla1*, Aparna2, Rukamani Nair3

1. Senior Biochemist (Scientist C), Dept. of Biochemistry, Room no. 411, Academic Block, G. B. Pant Institute of Post graduate Medical education and Research (GIPMER), JLN Marg, New Delhi 110002, Contact No. - +91 9718599055, E-mail - [email protected]

2. Analyst, Cognizant Technology Solutions, Calcutta-600096, Contact No. +91 9962751031, E-mail -

[email protected]

3. Naturopathy Expert, Bapu Nature Cure Hospital & Yogashram, Gandhi Nidhi, Mayur Vihar Phase 1, Delhi-91, Contact No. +91 9891775577, E-mail [email protected]

Article Received on - 25th April 2016 Article Revised on - 18th July 2016 Article Accepted on - 25th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Ranjna Chawla et.al., Effect of Different Intervals of Yoga and Naturopathy Treatments on Disease Activity Score, Symptom Score, Rheumatoid Factor, Uric Acid and Kidney Function Tests in Patients Suffering from Rheumatoid Arthritis, Int. J. Ayu. Alt. Med., 2016;

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RESEARCH ARTICLE *Corresponding Author Ranjna Chawla Senior Biochemist (Scientist C), Dept. of Biochemistry, Room no. 411, Academic Block, G. B. Pant Institute of Post graduate Medical education and Research (GIPMER), JLN Marg, New Delhi 110002, Contact No. - +919718599055, E-mail - [email protected]

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ABSTRACT: Aim of the present work was to study the effect of yoga therapy and yoga combined

with naturopathy treatment, for different intervals of time (1, 3,6,12 months), on regression of symptoms of rheumatoid arthritis (RA). Total of seventy five rheumatoid arthritis patients were enrolled and divided in three groups. Group 1 included 36 patients taking Allopathic medication. Group 2 included 39 patients taking naturopathy (massage, hot and cold fomentation applications) and yoga along with allopathic medication Group 3 included 36 patients taking yoga along with allopathic medication. Patients were investigated for joint swelling, visual analogue scale (VAS), disease activity score-28 (DAS28), rheumatoid factor (RF), uric acid levels and kidney function tests. In group given naturopathy and yoga therapy improvement in joint swelling, VAS, DAS was observed after 1, 3,6,12 months (p<0.001) and improvement in RA factor (p<.0.001) was observed after 12 months as compared to the base line values. In group receiving only yoga therapy improvement of Joint swelling was observed after 3 months (p<0.05), 6 months (p<0.01) and12 months (p<0.001) and improvement in DAS was observed after 3 months (p<.0.01), 6 months (p<.0.01) and 12 months (p<.0.001) as compared to baseline value. Significant improvement in VAS was observed from 1st month (p<.0.01) onwards till 12th month (p<.0.001). Creatinine levels were found to be significantly reduced after 12 months of yoga therapy (p<0.01). In control group given only allopathy improvement in VAS was observed after 6 months (p<.0.01) and 12 months (p<.0.001) and improvement in DAS was also observed after 6 months (p<.0.05) and 12 months (p<.0.01). Improvement in Joint swelling was seen only after 12 months (p<.0.05). The study concluded that combined effect of Yoga and Naturopathy resulted in earlier regression of symptoms. In yoga group the regular practice of Pranayama may have enhanced the power of the kidneys thus resulting in decreased levels of creatinine.

Key Words: Rheumatoid factor (RF), Disease Activity score- a 28joint count (DAS28), visual analogy scale (VAS), Rheumatoid factor (RF)

INTRODUCTION Rheumatoid arthritis (RA) is a systemic inflammatory disease affecting the structural integrity and function of musculoskeletal joints and eventually the entire body [1]. Rheumatoid arthritis is a common autoimmune disease that is associated with progressive disability, systemic complications, early death, and socioeconomic costs.[2] Older age, a family history of the disease, and female sex are associated with increased risk of RA, although the sex differential is less prominent in older patients.[3] In spite of the fact that drug treatments for RA have improved markedly in the last few years. But arthritis cannot be cured and even the best medical care may be of little help. There is a great need for additional activities that patients can do themselves so as to reduce pain and disability. In Rheumatoid Arthritis patients it is important to maintain a balance between sedentary life, which may reduce inflammation, and exercise, which may relieve

stiffness and weakness. While traditional guidelines have restricted RA patients to only gentle exercise, research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength and overall functioning [4] and does not exacerbate pain or worsen the disease [5]. Physical activity is an essential part of the effective treatment of rheumatoid arthritis and yoga is one of the best types of exercises for treatment of RA. Yoga has been used as a means to explore the exterior and interior world and ultimately to achieve wisdom and knowledge of the sacred Indian texts: the Vedas, Upanishads, and Shastras.[6]It forms a complete exercise plan involving physical, physiological and psychological faculties of human being which significantly influences the musculo-skeletal system for persons suffering from chronic illnesses. Evidence for the effectiveness of alternative medicines in rheumatoid arthritis is inconclusive as studies are often too small and are

EFFECT OF DIFFERENT INTERVALS OF YOGA AND NATUROPATHY TREATMENTS ON DISEASE ACTIVITY SCORE, SYMPTOM SCORE, RHEUMATOID FACTOR, URIC

ACID AND KIDNEY FUNCTION TESTS IN PATIENTS SUFFERING FROM RHEUMATOID ARTHRITIS

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of short duration. Nevertheless, there is some evidence that certain supplements and naturopathy could have a role in managing the disease. [7] Keeping in view the aforesaid, the present study was planned to find out therapeutic potential of Yoga and Naturopathy at different interval of time (0, 3, 6 and 12 months) up to a period of one year in patients suffering from RA. The effect on physical activities was evaluated by studying the parameters like joint swelling, VAS, DAS-28. To find the effect of degradative products formed during intervention therapies on kidney function tests biochemical parameters like uric acid and kidney function tests were included in the study. The goal of treatment was to study the regression of symptoms like joint pain, swelling and visible deformity. MATERIALS AND METHODS The study (ethics committee clearance number 1) was conducted in department of research, Bapu Nature Cure Hospital in collaboration with department of Biochemistry, GIPMER. A total of Seventy five radiologically and serologically proven RA patients were enrolled and divided in two groups. Group 1included 36 patients taking allopathic medication Group 2 included 39 rheumatoid arthritis patients taking naturopathy, yoga and allopathic medication. Written consent was taken from all the patients and ethical guidelines were followed during the study. The study had due approval from ethical committee of the institution. Rheumatoid arthritis patients satisfying the American College of Rheumatology criteria for rheumatoid arthritis were recruited by inclusion and exclusion criteria [8] after baseline investigation patient were given intensive information, education and counselling about risk factor of the disease and importance of yoga and naturopathy. After their awareness and counselling about the disease, yoga and naturopathy modalities were administered to patients. Ethical clearance was taken from the ethical committee before the start of the experiment. Inclusion criteria: Patients of both the sex aged 25 to 60 years. Diagnosed patients of Rheumatoid Arthritis (RA) and satisfying the American College of Rheumatology criteria since past six weeks at least. Exclusion Criteria: Following patients were excluded from the study: 1) Patients having a past history of Severe Cardiac dysfunction (atrial fibrillation, Heart failure, myocardial infarction, uncontrolled hypertension, or stroke. 2) Patients with concurrent serious

hepatic disorders defined as AST and/or ALT > 3 times of the upper normal limit. 3) Patients with concurrent serious renal disorders defined as Serum creatinine > 4.0mg/dl. 4) Patients with concurrent serious pulmonary dysfunction. 5) Patients with other concurrent severe diseases. 6) Patient with poorly controlled diabetes mellitus defined as Glycosylated haemoglobin (HbA1c) > 10%. 7) Patient with cerebrovascular event during the last 12 months. 8) Women who are pregnant or lactating. 9) Alcoholics. 10) Drug abusers.11) Patient with history of malignancy within past 2 years TREATMENT 1) Naturopathy Treatment a) Massage: patients were provided massage to the affected parts using warm sesame oil having anti-inflammatory properties (50 ml per sitting) for 30 minutes. The techniques used were stroking, friction, kneading, percussion and vibration. Massaging directly to the inflamed joint was avoided in the treatment course. During inflammation massage was given to the areas which were above and below the affected joints to reduce inflammation. b) Hot and cold fomentation was provided to every patient for 11 minutes – hot fomentation for 5 minutes and cold fomentation for 30 seconds for two rounds. This was followed by a heating compress (using a dry cotton cloth and woollen flannel) for 10 minutes. The temperature of both hot fomentation (40°- 45 °C) and cold fomentation (18°- 26 °C) was controlled well during the treatment period. The duration of cold therapy was less than heat therapy. This was because effect of cold is known to last longer than heat. 2) Yoga Therapy: The yoga therapies (20 min), practiced were Pawanmuktasana part I (anti-rheumatic), Shavasana and Pranayama (Bhramari, Kapalbati, Deep breathing and Nadisodhana) (Gheranda Samhita). The total treatment period for each patient was one year. Therapies were administered thrice a week on alternate days for first two months (1-2) then followed by twice in a week for the next four months (3-6) and in last six months (7-12) once a week. On days without session, patients were advised to continue this practice for 20-25 minutes at home. The daily adherence to this program was evaluated by analyzing questionnaire that was collected every month. The treatment was modified or omitted to avoid strain, whenever there was any inflammation in the joints. Yoga and naturopathy therapist followed the specific recommendations of orthopaedic surgeon for safe and healthy execution of treatment.

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3) Allopathic Medicines For delay in progression of RA, allopathic treatments were used in conjunction with yoga and naturopathy regime. The prescribed disease modifying drugs were Methotrexate, Sulfasalazine and Hydroxy chloroquine. For better management of the disease conditions, drugs like calcium and folate were also administered as per specific requirement. The doses were kept stable and the participants were asked to consult rheumatologists at the end of every month to review the medication. Principles of treatment remained same in both the groups and doses were modified according to the activity of disease. PARAMETERS STUDIED Biochemical parameters- Urea, Creatinine, uric acid were estimated spectrophotometrically after 1, 3, 6 and 12 months. Immunological markers- The blood samples were taken for Rheumatoid factor (RF) prior to the intervention and after a period of 12 months. [9] Physical parameters- Visual Analogue Scale (VAS): Pain intensity was measured after 1, 3, 6 and 12 months on Visual Analogue Scale (VAS) [10], which features a horizontal line usually 10centimeters (100 mm) in length, with the words ‘NO PAIN’ on the left and ‘WORST PAIN’ on the right; the patient makes a mark on the line to indicate the point on the spectrum that reflects how he or she is feeling. Disease activity score (DAS-28): Disease activity was evaluated after 1, 3, 6 and 12 months by using DAS-28 test [11] using four variables –tender joint count, swollen joint count, ESR and

patient’s general assessment of disease activity. The test, generates a disease activity score (DAS) based on an examination of 28 joints in the shoulders, arms, hands and knees. DAS28 combines a joint count, lab test (either the ESR or CRP) and VAS. For calculating DAS28 the following formula was used: DAS28 = 0.56 * square root (tender28) + 0.28 * square root (swollen28) + 0.70 * ln (ESR) + 0.014 * VAS The DAS-28 provides with a number on a scale from 0 to 10 indicating the current activity of the rheumatoid arthritis of patient. A DAS-28 above 5.1 means high disease activity whereas a DAS-28 below 3.2 indicates low disease activity. Remission is achieved by a DAS-28 lower than 2.6. Joint swelling- is the build up of fluid in the soft tissue surrounding the joint. When a joint is affected by arthritis, inflammatory in particular, abnormal amounts of fluid build up and making the joint swollen. Swollen joints of the patients were measured in terms of numerical values such as 3- severe, 2-moderate, 1-mild and 0- normal [12]. 4. Statistical Methods Results are expressed as mean ± standard deviation (SD). Student’s paired t test (two-tailed) from baseline to 1,3,6,12 months was computed. RESULTS A significant improvement (p<.0.001) in joint swelling was observed after 1, 3, 6 and 12 month of naturopathy with yoga therapy. The improvement observed after yoga therapy was p<0.05 (3 months), p<0.01(6 months) and p<0.001(12 months). After allopathy treatment the significant effect observed in joint swelling was only after 12 months (P< 0.05) (Table 1)

Table 1: Values of Joint swelling (measured in terms of numerical values 3- severe, 2-moderate, 1-mild and 0- normal) in

control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy Treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 2.06 ±0.71 2.0±0.56 2.11 ± 0.71 1month (P-value)

2.0 ±0.68 (0.735)

1.54 ±0.6 (0. 0007) ***

2 ± 0.68 (0.437)

3 months (P-value)

1.83±0.81 (0.221)

1.23 ±0.63 (< .00001) ***

1.75 ± 0.81 (0.022) *

6 months (P-value)

1.81 ±0.82 (0.172)

1.31 ±0.8 (.000032) ***

1.67 ± 0.82 (0.0100) **

12 months (P-value)

1.56±0.97 (0..0151) *

0.74 ±0.64 (< .00001) ***

1 ± 0.97 (< .00001) ***

*p < 0.05, **p < 0.01, ***p < 0.001

After Yoga and naturopathy treatment a significant improvement (p<.0.001) in VAS was observed after 1 month onwards till 12 months. After Yoga treatment also significant improvement was observed but the level of significance was p<.0.01

after 1 month and p<.0.001 after 3, 6, 12 months. After allopathic treatment the significant effect was observed only after6 months (p<.0.01) and 12 months (p<.0.001) (Table 2).

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Table 2: Values of VAS (mm) in control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 64.44 ±14.82 65.26 ±12.14 66.53 ± 10.03 1month (P-value)

62.17 ±15.44 (0.526)

53.59±11.7 (0.001) ***

57.64 ± 13.12 (0.0052) **

3 months (P-value)

58.42 ±17.72 (0.122)

39.62±10.41 (0.001) ***

48.92 ± 14.47 (<0.001) ***

6 months (P-value)

51.81 ±16.87 (0.0012) **

31.15 ±14.76 (0.001) ***

42.83 ± 17.88 (<0.001) ***

12 months (P-value)

45.97±19.27 (0.001) ***

16.67±12.43 (0.001) ***

26.39 ± 19.81 (<0.001) ***

*p < 0.05, **p < 0.01, ***p < 0.001

In DAS-28 a significant improvement was observed after 1 month (p<.0.01) and 3, 6 and 12 month (p<.0.001) of naturopathy with yoga treatment. In group getting only yoga therapy effect was observed after 3 and 6 months (p<.0.01) and 12

months (p<.0.001). After allopathic treatment the significant effect was observed only after 6 months (p<.0.05) and 12 months (p<.0.01) (Table 3).

Table 3: Values of DAS-28 (number on a scale from 0 to 10) in control and treatment groups after a period of 1, 3, 6 and 12

months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy Treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 7.06±1.07 6.89 ±1.05 7 ± 1.18 1month (P-value)

7±1.18 (0.82)

6.2 ±1.08 (0.0076) **

6.69 ± 1.17 (0.27)

3 months (P-value)

6.88 ±1.14 (0.49)

5.41 ±1.11 (0.001) ***

6.17 ±1.16 (0.0036) **

6 months (P-value)

6.49 ±1.34 (0.05) *

4.85 ±1.55 (0.001) ***

5.92 ± 1.64 (0.002) **

12 months (P-value)

5.86 ±1.7 (0.006) **

3.63 ±1.35 (0.001) ***

4.53 ± 1.95 (0.001) ***

*p < 0.05, **p < 0.01, ***p < 0.001

A significant improvement in RA factor (p<.0.001) was observed after 12 months of naturopathy with yoga treatment group. After yoga treatment and in

control group the decrease observed was not significant (Table 4).

Table 4: Values of RA factor (U/ml) in control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy Treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 120.94 ±93.99 174.72 ±120.05 164.56 ± 117.71 12 months (P-value)

127.06 ±91.79 (0.598)

111.82 ±79.63 (0.000) ***

142.25 ± 105.15 (0.548)

*p < 0.05, **p < 0.01, ***p < 0.001

No significant effect was observed in levels of uric acid or urea in any of the three groups (Table 5, 6, 7). Creatinine levels decreased after 12 months in yoga treatment (p<.0.01).

Table 5: Values of uric acid (mg/dl) in control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 4.46±1.64 4.85 ± 1.45 4.24 ± 1.20 1month (P-value)

4.25 ±1.67 (0.589)

4.48 ±1.13 (0.220)

4.02 ± 1.05 (0.422)

3 months (P-value)

4.53±1.58 (0.848)

4.54 ±1.30 (0.335)

4.08 ± 1.41 (0.609)

6 months (P-value)

4.69±1.66 (0.559)

4.62 ±1.13 (0.440)

4.25 ± 1.34 (0.955)

12 months (P-value)

4.77±2.14 (0.498)

4.93 ±1.41 (0.807)

4.87+1.49 (0.051)

*p < 0.05, **p < 0.01, ***p < 0.001

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Table 6: Values of urea (mg/dl) in control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month 23.97±7.24 22.69±7.24 23.75 ± 7.11 1month (P-value)

23.50±5.6 (0.742)

23.77±6.80 (0.500)

23.39 ± 7.26 (0.805)

3 months (P-value)

23.0±5.93 (0.509)

23.03±7.10 (0.837)

22.67 ± 6.94 (0.461)

6 months (P-value)

24.83±7.07 (0.592)

26.15±6.98 ( 0.35)

26.33 ± 11.15 (0.246)

12 months (P-value)

26.25±6.13 (0.130)

24.97±10.33 (0.262)

24.86 ± 6.81 (0.576)

*p < 0.05, **p < 0.01, ***p < 0.001

Table 7: Values of creatinine (mg/dl) in control and treatment groups after a period of 1, 3, 6 and 12 months

Duration of treatment

Control group (MEAN ± SD)

Yoga and naturopathy treatment group (MEAN ± SD)

Yoga group (MEAN ± SD)

0 month

0.91±0.15

0.88±0.15

0.87 ± 0.15

1month (P-value)

0.91±0.16 (0.946)

0.91±0.16 (0.464)

0.84 ± 0.20 (0.559)

3 months (P-value)

0.80±0.15 (0.064)

0.80±0.14 (0.088)

0.80 ± 0.17 (0.085)

6 months (P-value)

0.87±0.28 (0.432)

0.86±0.22 (0.679)

0.80 ± 0.16 (0.059)

12 months (P-value)

0.85±0.19 (0.144)

0.84±0.24 (0.370)

0.74 ± 0.20 (0.0035) **

*p < 0.05, **p < 0.01, ***p < 0.001

DISCUSSION The present study has shown the effect of different intervals of yoga treatment and naturopathy along with yoga treatments on symptom score, disease activity score, immunological and biochemical parameters in RA patients. Joint counts are a component of the core clinical data set for RA and will continue to play a key role in the near future. Using the 28-joint count has the benefit of simplicity and takes less time [13]. In our study also disease activity was studied by looking the effect on 28-joint count; besides this effect on joint swelling and VAS was also seen. The present study has shown that following Naturopathy and yoga practice significant effect on joint swelling and DAS started appearing after 1 month of treatment whereas in yoga group such effect was seen after 3 months. VAS in both the groups started improving after 1 month of treatment. People with arthritis, often have decreased muscle strength, physical energy, and endurance in part due to tendency to be sedentary which results in more inactivity further leading to greater pain and disability. Yogic techniques involve isometric contraction which is known to increase skeletal muscle strength and reduce stress and anxiety; improve autonomic functions by triggering neuro hormonal mechanisms by the suppression of sympathetic activity [14].Yoga may serve as a valuable adjunctive therapy for improving physical function, mental

wellness, and overall quality of life among individuals with rheumatic disease. [15] In a study it has been reported that yoga for 6-10 week duration, carried out twice or thrice a week resulted in statistically significant improvement in pain, disability index, general health, and mood. [16] A growing body of evidence supports the belief that yoga benefits physical and mental health via down-regulation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). [17] Yoga is reported to reduce stress and anxiety, improves autonomic functions by triggering neurohormonal mechanisms by the suppression of sympathetic activity. [18] In patients receiving both treatments i.e. yoga and naturopathy better results were observed as compared to group receiving only yoga therapy. The improvement in joint swelling and DAS 28 score was there after 1 month of yoga and naturopathy in comparison to the effects observed after 3 months in group receiving only yoga therapy. In our study RA factor improved only in yoga and naturopathy group after 12 months. The additional benefits of message therapy and hot and cold fomentation may be the contributory factors. Therapeutic massage treatments, while able to achieve qualitative muscle release in an affected joint region, can also positively affect the physiological systems of a patient with RA and

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help to alleviate and prolong the deteriorating effects of the disease. [19] Therapeutic massage of the muscles and joints is a complementary therapy for managing the pain and stiffness associated with arthritis. In message therapy the systemic rubbing with hands helps to nourish not only the parts acted upon but also the whole body by its thermic and mechanical effects. It also increases the body metabolism. In a study by measuring grip strength pre and post massage therapy, that included wringing, skin rolling, circular, and friction type strokes, a significant improvement in mobility and function was observed in comparison to the control group [20]. Moreover, to increase formation and flow of synovial fluid in affected joints, treating the surrounding joint tissues with light friction and vibration and establishing a methodical treatment interval is suggested [21]. Since RA is a systemic disease, it can also create blockage in lymph nodes proximal to affected joints and thereby contributing to discomfort and pain experienced by the patient. The aforementioned gentle circular friction techniques have been used to help increase the delivery of oxygen and nutrients and assist in the removal of waste products surrounding the affected joints [22]. When the joint is in an acute inflammatory stage, massage is contraindicated. However, when in remission stage, massage can effectively manage symptoms, prevent inflammation, and reduce joint damage [2]. Therapeutic massage treatments, while able to achieve qualitative muscle release in an affected joint region, can also positively affect the physiological systems of a patient with RA and help to alleviate and prolong the deteriorating effects of the disease. [23] Research showed that adults with rheumatoid arthritis may feel a decrease in pain, as well as greater grip strength and range of motion in wrists and large upper joints, after receiving regular moderate-pressure massages for a 4-week period. [24] In Fomentation Therapy, the blood is stimulated and invigorated and white blood cells increase. When the heat is applied, the blood vessels dilate and with the cold they contract. This action causes the blood to surge back and forth, increasing the flow throughout the cavities, stimulating stagnant blood and lymph. This increases circulation to any organ or limb far more rapidly than normal circulation. When this happens, the healthy blood cells are concentrated in the activated area [25]. The Increased blood flow delivers needed oxygen and nutrients, and removes cell wastes. The warmth decreases muscle spasm, relaxes tense muscles, relieves pain, and can increase range of motion. Cold therapy produces vasoconstriction, which slows circulation thereby reducing

inflammation, soreness, muscle spasm, pain and temporarily relieving joint pain caused by an arthritis flare. It has been found that cold compression therapy improves the control of pain and might thus lead to improvement in range of movement and shorter hospital stay [26]. The regular practice of pranayama enhances the power of the kidneys as well cures kidney problems. It is less physically-demanding activity and so does not increase creatinine level as may happen in strenuous physical activity. In our study creatinine levels decreased after 12 months in yoga treatment. Yoga provides strength to body systems, thus making our organs (kidneys in this study) stronger. After three months of twice-weekly sessions consisting primarily of standing and seated asanas and meditation, the yoga group exhibited significant reduction in the serum levels of urea and creatinine [27]. However in our study no significant effect was observed in levels of uric acid or urea in any of the three groups. After allopathic treatment the significant effect observed in VAS and DAS after 6months onwards and in joint swelling after 12 months may be because of the allopathic treatment taken by the control group. The study shows that alternative complementary treatment taken along with allopathic may help to suppress symptoms earlier in RA patients. All the patients of group given fomentation after massage and after yoga therapy had good relief in pain, swelling and stiffness of muscles. Some patients in the treatment group were able to decrease or discontinue allopathic medications. Combinations of medications with naturopathy and yoga can provide important additional physical and psychological health benefits and help in the better management of chronic rheumatoid arthritis condition in a scientific manner. Yoga might be considered as an ancillary treatment for OA and RA.[28] Since studies of naturopathy and yoga have suggested potential benefits therefore the practice may have particularly strong appeal if it is capable of eliciting and maintaining patient adherence. [29] CONCLUSION Yoga when combined with naturopathy can be more effective and can give better results in RA patients. For this consistent efforts and adherence on part of the patient is required. Making it a lifelong habit can help in fast regression of symptoms. Acknowledgments This project is supported by ICMR and we are thankful for release of funds.

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REFERENCES 1. Osborn K. chasing the pain away. (electronic

version) Massage & Bodywork 2005; 20(3):138-143. 2. Firestein GS. Evolving concepts of rheumatoid arthritis.

Nature 2003;423: 356-61. 3. Firestein GS, Kelley WN, eds. Etiology and pathogenesis of

rheumatoid arthritis. Kelley's Textbook of Rheumatology. 8th ed. Philadelphia, Pa.: Saunders/Elsevier; 2009: 1035–1086.

4. Lineker SC, Bell MJ, Wilkins AL, Badley EM. Improvements following short term home based physical therapy are maintained at one year in people with moderate to severe rheumatoid arthritis. J Rheumatol 2001; 28(1):165-168.

5. Bearne LM, Scott DL, Harley MV, Exercise can reverse quadriceps sensorimotor dysfunction that is associated with Rheumatoid Arthritis without exacerbating disease activity, Rheumatology 2002;41(2):157-166

6. Feuerstein G. Yoga: The Technology of Ecstasy. Los Angeles, Jeremy P. Tarcher. 1989 pp 11-16

7. Vitetta L, Cicuttini F and Sali A. Alternative therapies for musculoskeletal conditions. Best Practice & Research: Clinical Rheumatology.2008; 22:499–522.

8. Guidelines for the management of rheumatoid arthritis, 2002 update. Arthritis Rheum. 2002 Feb; 46(2):328-46.

9. Hermann E, Vogt P, Müller W. Rheumatoid factors of immunoglobulin classes IgA, IgG and IgM: Methods of determination and clinical value. Schweizerische medizinische Wochenschrift. 1986; 116 (38): 1290–1297

10. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988; 18:1007–19.

11. Van der Heijde DM, van 't Hof MA, van Riel PL, Theunisse LA, Lubberts EW, van Leeuwen MA, van Rijswijk MH, van de Putte LB. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis. 1990 Nov; 49 (11):916-20

12. Thompson, P.W., Silman, A.J., Kirwan, J.R., Arthicular Indices of joint Inflammation in Rheumatiod Arthritis, Arthritis Rheum, 1987; 30(6) : 618-623.

13. Sengupta P. Health Impacts of Yoga and Pranayama: A State-of-the-Art Review Int J Prev Med. 2012 Jul; 3(7): 444–458.

14. .D. L. SCOTT and D. A. HOUSSIEN Joint assessment in rheumatoid arthritis. British Journal of Rheumatology 1996;35(suppl.2):14-18

15. Matthew C Sullivan BA, Elena Manning BS and Raveendhara R Bannuru Yoga for Rheumatic Conditions:

Potential Physical, Cognitive and Affective Advantages J Yoga Phys Ther 2014; 4:2

16. Evans S, Moieni M, Lung K, Tsao J, Sternlieb B, Taylor M, Zeltzer L: Impact of Iyengar yoga on quality of life in young women with rheumatoid arthritis. Clin J Pain 2013; 29(11):988-997.

17. Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010 Jan; 16(1):3-12.

18. Pallav SenguptaHealth Impacts of Yoga and Pranayama: A State-of-the-Art Review Int J Prev Med. 2012 Jul; 3(7): 444–458.

19. Anderson R B. Massage Today Researching the Effects of Massage Therapy in Treating Rheumatoid Arthritis December, 2007, Vol. 07, Issue 12

20. Field T, Diego M, Hernandez-Reif M, Shea J. Hand arthritis pain is reduced by massage therapy. Journal of Bodywork and Movement Therapies. 2007; 11:21–24.

21. Wine ZK. Russian medical massage: arthritis. (electronic version) Massage Magazine. 1995; 57:90-92.

22. Osborn K. Chasing the pain away. (electronic version) Massage & Bodywork, 2005; 20(3):138-143.

23. Robin B. Anderson. Researching the Effects of Massage Therapy in Treating Rheumatoid Arthritis. Massage Today. December, 2007, 7(12)

24. Field T, Diego M, Delgado J, Garcia D, Funk CG, Rheumatoid Arthritisin Upper Limbs Benefitsfrom Moderate Pressure Massage Therapy. Complementary Therapies in Clinical Practice. 2013 May; 19(2):101-3.

25. Darrin k. Poitras. Hot and cold towel therapy – fomentations https://youtube/7pcmms3otts13 Nov 2013

26. Kullenberg B, Ylipää S, Söderlund K, Resch S Postoperative cryotherapy after total knee arthroplasty: a prospective study of 86 patients. J Arthroplasty 2006; 21(8):1175–9.

27. Yurtkuran M, Alp A, Yurtkuran M, Dilek K. A modified yoga-based exercise program in hemodialysis patients: A randomized controlled study. Complement Ther Med. 2007;15:164–71.

28. Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for rheumatic diseases: a systematic review. Rheumatology 2013; 52(11): 2025-30.

29. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: a randomized controlled study. J Altern Complement Med 2012; 18(5): 463-472.

CITE THIS ARTICLE AS – Ranjna Chawla et.al., Effect of Different Intervals of Yoga and Naturopathy Treatments on Disease Activity Score, Symptom Score, Rheumatoid Factor, Uric Acid and Kidney Function Tests in Patients Suffering from Rheumatoid Arthritis, Int. J. Ayu. Alt. Med., 2016; 4(3):133-140 Source of Support – Financial grant for carrying out Research work: ICMR Conflict of Interest – None Declared

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Paheerathan V., Pawmitha. M.F.F, Effectiveness of Root Decoction of Indigofera Tinctoria on Peptic Ulcer (Gunmam), Int. J. Ayu. Alt. Med., 2016; 4(3):141-148

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RESEARCH ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

EFFECTIVENESS OF ROOT DECOCTION OF Indigofera tinctoria ON PEPTIC ULCER (GUNMAM)

Paheerathan V.1*, Pawmitha. M.F.F.2

1. Senior Lecturer, Unit of Siddha Medicine, Trincomalee Campus, Sri Lanka, Contact No. +91772347677, Email - [email protected]

2. Intern Medical Officer, Base Ayurveda Hospital, Kapalthurai, Trincomalee, Sri Lanka, Contact No. +91 0778470575, Email - [email protected],

Article Received on - 30th May 2016 Article Revised on - 29th June 2016 Article Accepted on - 8th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Paheerathan V., Pawmitha. M.F.F, Effectiveness of Root Decoction of Indigofera Tinctoria on Peptic Ulcer (Gunmam), Int. J. Ayu. Alt. Med., 2016; 4(3):141-148

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RESEARCH ARTICLE

*Corresponding Author Paheerathan V. Senior Lecturer, Unit of Siddha Medicine, Trincomalee Campus, Sri Lanka, Contact No. +91772347677, Email - [email protected]

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ABSTRACT: This study is Quasi-experimental clinical trial to determine the effectiveness of root

decoction of Indigofera tinctoria in the management of Peptic ulcer (Gunmam). It also determines the association of Peptic ulcer with hereditary, food habits, physical activities and mental disturbances. The plant Indigofera tinctoria belongs to the family Fabaceae which popularly known as Avuri in Tamil. It is low shrub. Peptic ulcer disease is a problem of the gastrointestinal tract. The researcher administered questionnaire was used to collect the data. Ten (10) patients were selected clinically during the period of May 2015 to June 2015at the Rural Ayurvedic hospital, Kopalapuram. Patients were treated with 40ml of root decoction. Evaluation visits were made at baseline, 7th day, 14th day, 21st day, 27th day, 33rd day and 40th day. Effect of treatment was evaluated on changes in the sign and symptoms. Clinical parameters were analyzed by scores as difference between the visits on first day of treatment and after treatment. Statistically highly significant improvement (p<0.001) in heart burn, epigastric pain, indigestion, nausea & vomiting and eructation were observed in each visit while mean reduction also highly marked. On the basis of results and findings of this study shows remarkable reduction of degree of symptoms with highly significant improvement of the selected symptoms such as heart burn, epigastric pain, indigestion, nausea & vomiting and eructation.

Key Words: Indigofera tinctoria, Gunmam, Peptic ulcer, Decoction

INTRODUCTION Gunmam is a disease which is characterized by indigestion, burning sensation in stomach, vomiting, reduction in body strength, emaciation and depression. Moreover air increase inside the stomach cause pain resembling that of ball rolling subsequent to indigestion this disease referred as Gunmam, because it makes the patient to bend forward during attack of pain. During attack of pain patient psychologically get affected. [1], [2] This is the Quasi-experimental study to determine the internal administration of root decoction of Indigoferatinctoria (Avuri) in the treatment of Gunmampatients. Gunmam is compared with Peptic ulcer in modern aspect. Gunmam is characterized by severe stomach pain to the patients to the extent that the patient usually assumes a bent forward position in order to get relief from the pain.[3] “Vathapanthathonthamillathukunmamvatathu” The patient suffering from this disease will lean forward due to pain. Hence it is named as Gunmam. The other name for Gunmam in Siddha is Gulmam.[2] The common features of this disease are indigestion, stomach irritation, vomit, decrease in body weight, loss of confidence. It is caused due to consumption of very hot food stuffs, gastritis inducing foodstuffs, water mixed with limestone,

high consumption of coconut milk, stress, adequate temper, starvation and insomnia. Accordingto Siddha system the Gunmam is classified into 8 types such as Vaayukunmam, Vaathakunmam, Pithakunmam, Erikunmam, Valikunmam, Sattheekunmam, Sannikunmam and Iyakunmam. [3] The term ‘Peptic ulcer’ refers to an ulcer in the lower Oesophagus, stomach or duodenum, in the jejunum after surgical anastomosis to the stomach or rarely, in the ileum adjacent to a Meckel’s diverticulum. Ulcers in the stomach or duodenum may be acute or chronic; both penetrate the muscularis mucosae but the acute ulcer shows no evidence of fibrosis. Erosions do to not penetrate the muscularis mucosae. [4] The prevalence of Peptic ulcer (0.1-0.2%) is decreasing in many Western communities as a result of widespread use of Helicobacter pylori eradication therapy but it remains high in developing countries. The male to female ratio for duodenal ulcer varies from 5:1 to 2:1, whilst that for gastric ulcer is 2:1 or less. Chronic gastric ulcer is usually single; 90% are situated on the lesser curve within the antrum or at the junction between body and antral mucosa. Chronic duodenal ulcer usually occurs in first part of the duodenum and 50% are on the anterior wall. [4]

EFFECTIVENESS OF ROOT DECOCTION OF Indigofera tinctoria ON PEPTIC ULCER (GUNMAM)

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Peptic ulcer disease is a problem of the gastrointestinal tract characterized by mucosal damage secondary to pepsin and gastric acid secretion. It usually occurs in the stomach and proximal duodenum; less commonly, it occurs in the lower oesophagus, the distal duodenum, or the jejunum, as in unopposed hyper secretory states such as Zollinger-Ellison syndrome, in hiatal hernias (Cameron ulcers), or in ectopic gastric mucosa (e.g., in Meckel’s diverticulum). [5]

The number of diseases treated with herbs which are common in Siddha System of medicine. The herbs used in different forms for various diseases. There are many specific herbs available to cure peptic ulcer. Indigofera tinctoria (Avuri) is one such herb. In the Siddha system this herb is considered to be effective medicine for Peptic ulcer.[6] The plant Indigofera tinctoria belongs to the family Fabaceae which popularly known as Neeli in Tamil. A low shrub, 60-120cm tall with numerous, virgate, slightly angular branches, more or less covered with white adpressed hairs; leaves alternate, impair pinnate, rachis 3.7-5cm long, adpressedpilose, leaflets 7-11, shortly stalked with minute stipels, about 1.2-1.8cm long; flowers irregular, bisexual, small, pink, on short, slender pedicels: fruit a many seeded, cylindrical legume, 2.5-3cm long, linear, straight curved.[7]

According to Kunapadam (muthalpaham) Porutpanbunool

“Ella vidankalukumetramuripakum Pollachchuramoorchaiponkuvedai- nillap Pavatitharunkkunmamuthalpannoyolium

Avurithatumvetukkari” According to above stanza the word “Gunma muthalpannoyozhiyum” indicates root of Avuri cures Peptic ulcer. Peptic ulcer is common gastrointestinal disorder. There are number of medicines available in allopathic and indigenous medical system for peptic ulcer. However the prevalence of Peptic ulcer is increased due to the life style pattern. Therefore researcher try to prove the root of Indigoferatinctoriacan cure the Peptic ulcer which states in Gunapadampart.[6] Objective of the research To identify the effectiveness of root decoction of Indigoferatinctoria onPeptic ulcer (Gunmam) METHODOLOGY This is a Quasi-Experimental study. In this study, Peptic ulcer patients were selected based on inclusive criteria and exclusive criteria at the Rural Ayurvedic hospital, Kopalapuram. The selected drugs were administrated for forty days with seven intervention treatment arms.

Study area The study area was the Kopalapuram in Trincomalee district. The study was carried on Rural Ayurvedic Hospital, Kopalapuram. STUDY DESIGN This is a randomized clinical trial. Peptic ulcer patients, according to the inclusive criteria, were selected at the Rural Ayurvedic hospital, Kopalapuram during May 2015- June 2015. The selected patients were treated with selected drugs. The selected drugs were administrated for forty days with seven intervention treatment arms. All the selected patients were interviewed by the researcher on their first visit to the OPD. They were assured that all information obtained from them would be strictly confidential. Treatment allocation depended only on the time sequence in which patients entered the study, thus minimizing selection bias. The drug selected for this study was prepared by researcher. Ten patients were selected. These patients were selected within the study time frame (May 2015- June 2015), using inclusion and exclusion criteria based on the signs, symptoms of Peptic ulcerin the first phase of the screening procedure. The purpose of the trial was explained to the patients and those who volunteered signed ‘informed consent’ to enroll in the trial (The ‘informed consent’ form is shown in Annexure II). Ethical clearance was obtained from Ethical Review Committee, Institute of Indigenous Medicine, University of Colombo. Selection of Peptic ulcer patients Ten patients were selected for this study. Patients were selected based on inclusive and exclusive criteria. Patients between the age group of 20-60 years, both sexes presenting with the sign and symptoms of Peptic ulcer were randomly selected from Outpatients Department of the Rural Ayurvedic Hospital, Kopalapuram and were subjected to clinical examination. During the period of study (May 2015- June 2015), 10 patients were examined by the researcher for Peptic ulcer at the Rural Ayurvedic Hospital, Kopalapuram. These patients were subjected to a detailed clinical examination based on proforma especially prepared for this study. Diagnosis was made on the basis of the history and physical examination. The following physical examination was made by the researcher;

1. Addavithapatidchai (villi, molli, navu, naddi, malam, siruner, sparisam, niram)

2. Blood Pressure and Pulse

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3. In systemic examination special emphasis was given to the Gastrointestinal System. In addition to this Cardiovascular System and Respiratory System were also examined by the researcher.

Inclusion criteria Patients were selected in either gender and between the age group of 20- 60 years. Diagnosis of peptic ulcer based on typical history. Any three of following sign and symptoms,

o Epigastric pain o Heart burn o Indigestion o Eructation o Nausea and vomiting

Exclusion Criteria

o Pregnant & lactating mother o Patient with ongoing medication of peptic

ulcerin Allopathic system. o Patient below the age of 19 years and above

the age of 61 years o Patient with ongoing medication for any

disease Purification and Preparation of drug Plant material (root) was collected and purified by removing sand, small stones, washed with water, boiled in milk and dried in shade. Finally researcher has obtained the purified Avuriroot. The drug was prepared by standard method for decoction (PonRamanathan, 2000). Raw material of root of Indigoferatinctoria - 35g and Water - 625ml. Instrument The instrument used in this study is an interviewer (researcher) administrated questionnaire or proforma. In addition to responses to specific questions, notes were made on information obtained by examination. The follow-up of the patients were recorded at every one week interval. These questions were prepared based on specific objectives. It was heated and reduced into 1/8th

(~80ml). Data collection Ten patients were selected for this study. Patients were selected based on inclusive and exclusive criteria. Patients between the age group of 20-60 years, both sexes presenting with the sign and symptoms of Peptic ulcerwere randomlyselected from Outpatients Department of the Rural Ayurvedic Hospital, Kopalapuram and were subjected to clinical examination. During the

period of study (May 2015- June 2015), 10 patients were examined by the researcher for Peptic ulcer at the Rural Ayurvedic hospital, Kopalapuram. The purpose of trial was explained to the patient to get their consent a selected patient was interviewed by the researcher on their first visit to the OPD. The patient were subjected to a detailed clinical examination based on proforma specially prepared this study. Diagnosis will be made on the basis of history and clinical examination. Treatment All selected patient were treated with 40ml of Avuriver kudineer twice a day for 40 days. Clinical evaluation Evaluation visit were made at base line and once in a week for 06 weeks. Effect of treatment was evaluated on the basis of changes in the signs and symptoms after the treatment. Epigastric pain, heart burn, indigestion, nausea & vomiting and eructation were considered as clinical parameters and changes were recorded at every visit. Clinical parameters were analyzed by score as difference between the visits on first day of the treatment, seventh day, fourteenth day, twenty-first day of the treatment and end of the treatment (40th day). Clinical signs and symptoms of each patient were assessed on the basis of changes in signs and symptoms of the disease. Data analysis The data was analysed using the Statistical Package for Social Sciences (SPSS) version16. Dependent variables and independent variables (chief complaint, food aggravating the symptoms, physical activities aggravating symptoms, family history, and patient’s satisfaction) are used to measure the effectiveness of decoction of Indigoferatinctoria. RESULTS AND COMMENTS Results of clinical trial were considered in 10 patients with Peptic ulcer. Results are presented after treatment on 7th day, 14th day, 21st day and 40th day. The Table 1 indicates marked reduction in heartburn in patients with Peptic ulcer as measured on 7th day, 14th day, 21st day and 40th day. Patients showed significant improvement. The Mean value of heartburn before treatment was 1.80.Mean values after treatment on 7th day and 14th day were 0.80and0.00respectively and Mean values for last 2 visits also same as 14th day. Showing mean difference of heartburn were 1.00 and 1.80 on 7th day and 14th day respectively. Mean difference were same as 14th day in last 2 visits.

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Table 1:- Effect of drug on Heartburn

Symptom (Epigastric pain)

Before treatment

After treatment 7th day 14thday 21stday 40thday

Mean 1.800 0.600 0.100 0.000 0.000

Mean reduction - 1.200 1.700 1.800 1.800 Standard deviation - 0.632 0.675 0.789 0.789 Standard Error Mean - 0.200 0.213 0.249 0.249 df - 9 9 9 9 Paired “t” - 6.000 7.965 7.216 7.216 P - <0.001 <0.001 <0.001 <0.001

Standard Deviation of heartburnwere±0.471 on 7th day and ±0.789 on all other visits. Standard Error Mean of heartburn were 0.149 on 7th day and 0.249 on all other visits, t value were 6.708, 9.798

on 7th day and 14th day respectively and 7.216 on other two visits, p value were <0.001 in all visits. Degree of Freedom (df) 9 in every visits.

Table 2:- Effect of drug on Epigastric pain

Symptom

(Indigestion) Before

treatment After treatment

7th day 14thday 21stday 40thday Mean 1.40 0.40 0.00 0.00 0.00

Mean reduction - 1.00 1.40 1.40 1.40 Standard deviation - 0.667 0.699 0.699 0.699 Standard Error Mean - 0.211 0.221 0.221 0.221 df - 9 9 9 9 Paired “t” - 4.743 6.332 6.332 6.332 P - 0.001 <0.001 <0.001 <0.001

The Mean value of epigastric pain before treatment was 1.80. Mean values after treatment on 7th day and 14th day were 0.60 and 0.10 respectively and Mean values for last 2 visits were 0.00. Showing mean difference of epigastric pain were 1.20, 1.70 and 1.80 on 7th day, 14th day and 21st day respectively. Mean difference was same as 21stday in last visit. Standard Deviation of epigastric pain were ±0.632, ±0.675 and ±0.789 on 7th day, 14th

day and 21st day respectively. Standard Deviation was same as 21stday in 40th day. Standard Error Mean of epigastric pain were 0.200, 0.213 and 0.249 on7th day, 14th day and 21st day respectively. Standard Error Mean was same as 21stday in 40th day, t value were 6.000, 7.965 and 7.216 on 7th day, 14th day and 21st day respectively and t value same as 21stday in 40th day , p value were <0.001 in all visits. Degree of Freedom (df) 9 in every visits.

Table 3:- Effect of drug on Indigestion

Symptom

(Indigestion) Before

treatment After treatment

7th day 14thday 21stday 40thday Mean 1.40 0.40 0.00 0.00 0.00 Mean reduction - 1.00 1.40 1.40 1.40 Standard deviation - 0.667 0.699 0.699 0.699 Standard Error Mean - 0.211 0.221 0.221 0.221 df - 9 9 9 9 Paired “t” - 4.743 6.332 6.332 6.332 P - 0.001 <0.001 <0.001 <0.001

The Mean value of indigestion before treatment was 1.40. Mean values after treatment on 7th day and 14th day were 0.40and 0.00 respectively and Mean values for 21st day and 40th day also same as 14th day. Showing mean difference of indigestion were 1.00 and 1.40 on 7th day and 14th day respectively. Mean difference were same as 14th day in 21st day and 40th day. Standard Deviation of

indigestion were ±0.667 on 7th day and ±0.699 on all other visits. Standard Error Mean of indigestion were 0.211on 7th day and 0.221 on all other visits, t value were 4.743, on 7th day and 6.332 in on all other visits, p value were 0.001 on 7th day and <0.001 in all other visits. Degree of Freedom (df) 9 in every visits.

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Table 4:- Effect of drug on Nausea & vomiting

Symptom (Eructation)

Before treatment

After treatment 7th day 14thday 21stday 40thday

Mean 1.60 0.70 0.00 0.00 0.00

Mean reduction - 0.90 1.60 1.60 1.60 Standard deviation - 0.316 0.843 0.843 0.843 Standard Error Mean - 0.100 0.267 0.267 0.267 Df - 9 9 9 9 Paired “t” - 9.000 6.000 6.000 6.000 P - <0.001 <0.001 <0.001 <0.001

The Mean value of nausea & vomiting before treatment was 1.40. Mean values after treatment on 7th day and 14th day were 0.30 and 0.10 respectively and 0.00 in last 2 visits. Showing mean difference of nausea & vomiting were 1.10, 1.30 and 1.40 on 7th day, 14th day and 21st day respectively. Mean difference was same as 21st day in 40th day. Standard Deviation of nausea & vomiting were ±0.568, ±0.675 and ±0.843 on 7th day, 14th day and 21st day respectively. Standard

Deviation was same as 21st day in 40th day. Standard Error Mean of nausea & vomiting were 0.180, 0.213 and 0.267on 7th day, 14th day and 21st day respectively. Standard Error Mean was same as 21st day in 40th day, t value were 6.128, 6.091 and 5.250 on 7th day, 14th day and 21st day respectively and t value same as 21st day in 40th day , p value were <0.001 in 7th day and 14th day and 0.001 in 21st day and 40th day. Degree of Freedom (df) 9 in every visits.

Table 5:- Effect of drug on eructation

Symptom

(Eructation) Before treatment After treatment 7th day 14thday 21stday 40thday

Mean 1.60 0.70 0.00 0.00 0.00

Mean reduction - 0.90 1.60 1.60 1.60 Standard deviation - 0.316 0.843 0.843 0.843

Standard Error Mean - 0.100 0.267 0.267 0.267 Df - 9 9 9 9

Paired “t” - 9.000 6.000 6.000 6.000 P - <0.001 <0.001 <0.001 <0.001

The Mean value of eructation before treatment was 1.60. Mean values after treatment on 7th day and 14th day were 0.70and 0.00 respectively and Mean values for 21st day and 40th day also same as 14th day. Showing mean difference of eructation were 0.90 and 1.60 on 7th day and 14th day respectively. Mean difference were same as 14th day in 21st day

and 40th day. Standard Deviation of eructation were ±0.316 on 7th day and ±0.843 in all other visits. Standard Error Mean of eructation were 0.100 on 7th day and 0.267 in all other visits, t value were 9.000, on 7th day and 6.000 in all other visits, p value were <0.001 in all visits. Degree of Freedom (df) 9 in every visits.

Overall effect of treatment

Figure 1:- Overall effect of treatment

0

0.5

1

1.5

2

beforer treatment 7th day 14th day 21st day 40th day

Mea

n va

lue

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DISCUSSION Effect of drug on Heartburn Statistically highly significant improvement (p<0.001) in heartburn was observed in 7th day, 14th day, 21st day and 40th day in patients with Peptic ulcer (based on paired T test) while mean reduction of heartburn in Peptic ulcer is highest indicating the effect of the drug. Effect of drug on Epigastric pain Statistically highly significant improvement (p<0.001) in epigastric pain was observed in 7th day, 14th day, 21st day and 40th day in patients with Peptic ulcer (based on paired T test) while mean reduction of epigastric pain in Peptic ulcer is highest indicating the effect of the drug. The Table 2 indicates marked reduction in epigastric pain in patients with Peptic ulcer as measured on 7th day, 14th day, 21st day and 40th day. Patients showed significant improvement. Effect of drug on Indigestion Statistically highly significant improvement (p<0.001) in indigestion was observed in 7th day, 14th day, 21st day and 40th day in patients with Peptic ulcer (based on paired T test) while mean reduction of indigestion in Peptic ulcer is highest indicating the effect of the drug. Table 3 indicates marked reduction in indigestion in patients with Peptic ulcer as measured on 7th day, 14th day, 21st day and 40th day. Patients showed significant improvement. Effect of drug on Nausea & vomiting Statistically highly significant improvement (p<0.001) in nausea and vomiting was observed in 7th day, 14th day, 21st day and 40th day in patients with Peptic ulcer (based on paired T test) while mean reduction of nausea and vomiting in Peptic ulcer is highest indicating the effect of the drug. Table 4 indicates marked reduction in nausea and vomiting in patients with Peptic ulcer as measured on 7th day, 14th day, 21st day and 40th day. Patients showed significant improvement. Effect of drug on eructation Statistically highly significant improvement (p<0.001) in eructation was observed in 7th day, 14th day, 21st day and 40th day in patients with Peptic ulcer (based on paired T test) while mean reduction of eructation in Peptic ulcer is highest indicating the effect of the drug. Table 5 indicate marked reduction in eructation in patients with Peptic ulcer as measured on 7th day, 14th day, 21st day and 40th day. Patients showed significant improvement

Overall effect of treatment Effectiveness is explained on the basis of Rasa, Veeriya, Vipaka, action and properties of Vata and Pitta. Gunmam(Peptic ulcer) is one of Vatharogam. Vitiated Vāta lodged in stomach. Hence to treat Gunmam drugs acting on Vāta and Amashaya (stomach) should be selected. In the Amashaya (diseases in the stomach) the treatment should be given bitter substance. In the root decoction of Indigofera tinctoria has bitter taste. Bitter taste has vayu and akashsa Mahabhutas in dominance. Hence it has got affinity towards some locations like Amashaya. Though, bitter aggravates vayu which may enhance the pathogenic process of Gunmam and main dosha involved in Gunmam is vayu. The trial drug i.e., Indigofera tinctoria has bitter taste, Ushna Viriya and pungent (Karppu) Vipaka. Bitter taste has got Deepana (facilitate digestion) and Pachana (augment digestion) properties. So it helps to improve the digestion and helps in the management of Peptic ulcer. Bitter taste may act as anti-inflammatory agent and can reduce the inflammation in the stomach. Madhura and Karppuu Vipaka are pacifying the Vata vitiation. Above explanation has been supported by the results obtained from this study; therefore the quotation for general character of Indigofera tinctoria is proven from the above scientific study for the Peptic ulcer. RECOMMENDATION The root of Indigofera tinctoria for treatment of Peptic ulcer since it is a under graduate research procedure there for the future research can be considered of prolongation of the study period and which are the active ingredients responsible for the Peptic ulcer. CONCLUSION On the basis of results and findings of this Quasi-experimental clinical trial on root decoction of Indigofera tinctoria for Peptic ulcer show remarkable reduction of degree of symptoms with highly significant improvement of the selected symptoms such as heart burn, epigastric pain, indigestion, nausea & vomiting and eructation. REFERENCES

1. Sanmugavelu M. NoiNadalNoiMuthalNadal part-2(2010) Indiamaruthuvam- Homiopathythurai, Chennai- 600106; pp.254-268.

2. KuppusamiMuthaliyar K.N. Siddha Maruthuvam (Pothu) (2004), InthiyaMaruthuvamHomeopathythurai Chennai-600106, 6th edition; pp-299-318.

3. Sundaram V. Siddha Medicine for peptic ulcer. Heritage of Tamil Siddha Medicine (1983). Internal Institute of Tamil Studies. Taramani, Madrass 600113: pp-238-241.

4. Brain R. walker, Nicki R. Colledge, stuart h. Ralston, Ian D. Penman. Davidson’s Principles and Practice of Medicine, 22nd edition, 2014; pp-872-873.

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5. KalyanakrishnanRamakrishnan and Robert C. Salinas, (2007). Peptic Ulcer Disease. University of Oklahoma Health Sciences Center, Oklahoma City, Oklahom, 76(7).

6. MurugesaMutheliyar K.S. Gunapadam part-1 (Porutpanbunool) (2008) Indiamaruthuvam- homiopathythurai, Chennai- 600106.

7. Jayaweera D.M.A. Medicinal plants(Indigenous and Exotic) used in Ceylon(2006), The national science foundation 47/5, maitland place, Colombo-07, Sri Lanka.

CITE THIS ARTICLE AS – Paheerathan V., Pawmitha. M.F.F, Effectiveness of Root Decoction of Indigofera Tinctoria on Peptic Ulcer (Gunmam), Int. J. Ayu. Alt. Med., 2016; 4(3):141-148 Source of Support – Nil Conflict of Interest – None Declared

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RESEARCH ARTICLE Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

INTEGRATED APPROACH OF YOGA, NATUROPATHY AND PHYSIOTHERAPY IN THE MANAGEMENT OF OSTEOARTHRITIS OF

KNEES

Rukamani Nair1, Naorem Jiteswori Devi2*, Gaurav Kaushik3, V.N. Gaur4, Akhil Jain5

1. Medical Superintendent, Bapu Nature Cure Hospital and Yogashram, Mayur Vihar Phase-1, Delhi, Contact No. +919891775577, Email- [email protected]

2. Research Officer, Bapu Nature Cure Hospital and Yogashram, Mayur Vihar Phase-1, Delhi, Contact No. +919958659225, Email- [email protected]

3. Research Coordinator, Bapu Nature Cure Hospital and Yogashram, Mayur Vihar Phase-1, Delhi,

Contact No. +919871545296, Email- [email protected]

4. 4Orthopedic Surgeon, Ramlal Kundanlal hospital, Pandav Nagar, Delhi, Contact No. +919810038855, Email- [email protected]

5. Biostatistician, Bapu Nature Cure Hospital and Yogashram, Mayur Vihar Phase 1, Delhi., Contact

No. +919811948439, Email- [email protected]

Article Received on - 2nd May 2016 Article Revised on - 18th July 2016 Article Accepted on - 25th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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RESEARCH ARTICLE *Corresponding Author Naorem Jiteswori Devi Research Officer, Bapu Nature Cure Hospital and Yogashram, Mayur Vihar Phase-1, Delhi, Contact No. +919958659225, Email- [email protected]

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ABSTRACT: The aim of the study was to evaluate the effects of yoga, naturopathy and

physiotherapy treatments on the weight, BP, symptoms, functional status and Vitamin D3 of the elderly people having knee osteoarthritis. A total of 92 patients were allocated into two groups. Control group were on medicine and intervention group had undergone combined therapy of Yoga, Naturopathy, Physiotherapy and diet control. The study parameters were assessed at baseline, 6th and 12th month. Result of this study showed improvement in SF-12 MCS, pain scores and vitamin D3 in both the groups. However Weight, BP, Swelling, Morning Stiffness, SF-12 PCS and 50 foot walk test scores were significantly improved only in the intervention group. In conclusion, a combined package of yoga, naturopathy and physiotherapy with diet control was found to be effective in reducing pain, weight, BP, morning stiffness, swelling and in improving functional status and Vitamin D3 of the elderly people with osteoarthritis of knees.

Key Words: Osteoarthritis, Yoga, Naturopathy, Physiotherapy, Diet

INTRODUCTION Osteoarthritis (OA) is characterised primarily by articular cartilage degeneration and a secondary peri-articular bone response. Worldwide prevalence rate of OA is 20% for man and 41% for female respectively; causing dysfunction in 20% of the elderly. [1] OA is the second most common degenerative problem and the most frequent joint disease with prevalence of 22% to 39% in India. [2] The prevalence was higher in villages (31.1%) and big cities (33.1%) as compared to town (17.1%) and small cities (17.2%). [3] Globally, OA is the eight leading cause of disability and knee OA is more commonly associated with disability than any other joint. Risk factors of OA of knee include older age, obesity, osteoporosis, occupation, previous trauma, muscle weakness and genetic factors.[4] Yoga is commonly perceived as an alternative medicine. In Sanskrit word, Yoga means union or unification. Yoga techniques aim to develop and retain a healthy balance between all aspects of body and mind.[5] It offered an effective method for improving health in different aspects. Yoga therapy, as an adjunct treatment, enhanced pain, range of knee flexion, walking time, tenderness, swelling, crepitus, and knee disability in patients with OA knees.[6] Massage therapy had been evaluated and found to be effective for various painful musculoskeletal conditions.[7,8] It improved walking, pain, function, and QOL of middle-aged and older patients with knee osteoarthritis. [9] Another study found that Physiotherapy improved knee strength, reduced pain and improved knee

range of motion, walking and sit-to-stand activities in patient with OA knees.[10] Hot and Cold Compress was also useful treatment to reduce pain.[11] Alternating hot–cold water immersion was one of the very popular techniques in aiding recovery after physical training and competition.[12] It reduced knee symptoms and pain, and was considered to be the most appropriate protocol of treatment to relieve symptoms and pain. [13] There are no studies on combined treatment modalities of yoga, naturopathy and physiotherapy on osteoarthritis of knees. Hence this study was planned to assess the effect of combined therapies of yoga, naturopathy, physiotherapy and diet. Objective To evaluate the effectiveness of Yoga, Naturopathy and Physiotherapy in the treatment of Osteoarthritis of knees in reducing weight, Blood pressure, symptoms and improving Vitamin D3 and functional status. MATERIALS AND METHODS This study was conducted at Research and Development Department of Bapu Nature Cure Hospital and Yogashram. Recruitment of patients above 60 years of age was done through advertisements in wall posters, banners, organising camps in nearby localities of the hospital and from the hospital OPD. Adequate counselling was carried out for the disease awareness, effectiveness of the treatments in the study as well as about the study protocol. Eligible patients were recruited after taking consent

INTEGRATED APPROACH OF YOGA, NATUROPATHY AND PHYSIOTHERAPY IN THE MANAGEMENT OF OSTEOARTHRITIS OF KNEES

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according to the inclusion and exclusion criteria, as per American College of Osteoarthritis Association guidelines. The total period of recruitment was 12 months. Out of 113 patients recruited, 58 in intervention group (Yoga, Naturopathy, Physiotherapy and Diet control) and 32 patients in control group (Allopathic Medicines) had completed one year treatment and 23 patients opted out from the study. As this was an interventional study, double blinding was not possible. The statistician who did the randomization and data analysis and the researcher who carried out assessment were blinded to the treatment status of the subjects. Assessment Parameters investigated were -Weight, BP, symptom scores (morning stiffness, swelling and VAS-pain), Vitamin D3, SF-12 and 50 foot walk test (functional status), were assessed at baseline, 6th

and 12th month. Ethical consideration The approval from Institutional Ethics Committee was obtained. A signed informed consent of all subjects was obtained after explaining the study in detail. Intervention Yoga, naturopathy and physiotherapy treatments were provided to the intervention group twice in a week for four months and once in a week for 8 months (64 sessions). For providing medicine to the control group, patients were called once in a month for 12 months follow up. The study parameters were assessed at baseline, 6th and 12th month. Yoga, Naturotherapy and Physiotherapy modules were provided to the intervention group. The total treatment duration of Yoga, naturopathy and physiotherapy was one hour and 11 minutes [Table1].

Table 1. Intervention Module (1 hour and 11 mins)

Yoga module -15 minutes Naturopathy treatments-33minutes Physiotherapy treatment -22 minutes

1)Tadasana 2)Utakasana 3)Konasana 4)Uttanpadasana 5)Salabasana 6)Nadi shodhana 7)Pranayama 8)Brahmari pranayama

1)Leg Massage-15 mins 2)Hot and Cold Compress(temp Hot 420-450C, Cold 18-270C)- 18 min

1)Inferential therapy 2)Ultrasonic therapy 3)Isometric exercise 4)Strengthening exercise

RESULTS SPSS 17.0 was used to analyse the data. Pair t test was done to compare within the group. In control group, no significant improvement was found in Weight at 6th and 12th month as compared to baseline. Systolic Blood Pressure was increased at 6th month but not statistically significant. However at 12th month it was significantly increased as compared to baseline (p=0.032) and Diastolic blood Pressure was not significantly improved at 6th and 12th month in control group. Pain scores (VAS) was significantly reduced in control group at 6th and 12th month (p< 0.001) as compared to baseline. SF12 PCS (Physical component) scores were found insignificant at 6th and 12th month whereas SF12 MCS (Mental health component) scores were observed significant improvement at 6 month (p=0.004) and 12 month (p<0.001) as compared to baseline. Significant improvement were found in Serum Vitamin D3 level at 6th month (p<0.001)

and 12th month (p<0.001) after the treatment [Table 2]. In intervention group, significant reduction was observed in Weight at 6 month (p=0.002) and 12 month (p=0.012) as compared to baseline. Significant difference in Systolic Blood Pressure was observed at 6 month (p<0.001) and 12 month (p=0.001) as compared to baseline, however, Diastolic Blood Pressure was found to be improved significantly at 6 month (p=0.001) but not at 12 month (p=0.11) as compared to baseline. Two domains of SF12 i.e., PCS and MCS scores were improved significantly at 6th (PCS- p<0.001 and MCS- p=0.005) and 12 month (PCS- p=0.001 and MCS- p<0.001). Similarly, significant difference was found in Vitamin D3 level at 6 month (p<0.001) and 12 month (p<0.001) as compared to baseline. Pain score (VAS) was significantly reduced at 6th and 12th month (p<0.001) [Table 3]

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Table 2: Comparison within the control group (Baseline, 6th and 12th month)

Parameters Pre & post Mean + sd P value

Weight Baseline 62.78±16.87 6th month 62.15±16.77 0.655 12th month 62.79±16.37 0.991

B.p (systolic) Baseline 127.19±13.56 6th month 130.81±11.69 0.191 12th month 131.88±9.31 0.032

B.p (diastolic) Baseline 82.56±10.05 6th month 85.31±7.18 0.070 12th month 84.38±8.01 0.217

Vas

Baseline 68.75±14.75 6th month 48.75±24.46 <0.001 12th month 51.88±15.54 <0.001

Sf-12 pcs Baseline 40.64±5.99 6th month 40.90±5.68 0.111 12th month 41.29±4.71 0.642

Sf-12 mcs Baseline 33.19±5.24 6th month 36.94±5.77 0.004 12th month 42.09±4.77 <0.001

Vitamin d3 Baseline 5.36±17.23 6th month 16.10±12.51 <0.001 12th month 45.27±19.07 <0.001

Table 3: Comparison within the intervention group (Baseline, 6th and 12th month)

Parameters Pre & post Mean + sd P value

Weight Baseline 70.34±12.50 6th month 68.85±11.72 0.002 12th month 69.00±11.82 0.012

B.p (systolic) Baseline 136.14±17.45 6th month 127.28±11.80 <0.001 12th month 127.97±9.52 0.001

B.p (diastolic) Baseline 84.76±9.32 6th month 80.38±8.72 0.001 12th month 82.69±6.64 0.114

Vas Baseline 51.36±17.16 6th month 33.64±13.35 <0.001 12th month 34.60±13.70 <0.001

Sf-12 pcs Baseline 38.25±7.24 6th month 42.44±5.25 <0.001 12th month 42.09±3.35 0.001

Sf-12 mcs Baseline 35.78±6.08 6th month 39.73±8.97 0.005 12th month 39.91±4.80 <0.001

Vitamin d3

Baseline 2.99±2.51 6th month 19.54±15.34 <0.001 12th month 29.82±16.54 <0.001

Morning stiffness: In intervention group, morning stiffness was improved as 20.70% and 89.70% were observed to be in normal category at 6th and 12th month respectively as compared to baseline (10.30%); and 0% severity was at 6th and 12th month as compared to baseline 30%. However, in control group, 3.10% and 9.40% were found in normal at 6th and 12th month as compared to baseline (3.10%). Regarding severity, 43% were found at baseline but reduced to 18.80% and 15.60% at 6th and 12th month.

Swelling: In intervention group, swelling was found to be improved in normal category at 6th(58.60% ) and 12th (98.30% ) respectively as compare baseline (32.80%); and 0% severity was at 6th and 12th month as compared to baseline 10.30%. However, in control group, 18.30% were found in normal at 6th and 12th month as compared to baseline (3.10%). Severity was reduced at 6th (3.10%) but not in 12th month (6.20%) as compared to baseline (6.20%).

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Table 4. Comparison on Morning Stiffness and Swelling (Baseline, 6th and 12th month) in Control Group

Control group Parameters Baseline 6th Month 12th Month Morning stiffness Normal 3.10% 3.10% 9.40% Mild 21.90% 43.80% 28.10% Moderate 31.20% 34.40% 46.90% Severe 43.80% 18.8% 15.60% Swelling Normal 9.40% 18.80% 18.80% Mild 28.10% 46.90% 43.80% Moderate 56.20% 31.20% 31.20% Severe 6.20% 3.10% 6.20%

Table 5. Comparison on Morning Stiffness and Swelling (Baseline, 6th and 12th month) in Intervention Group

Group -II (Yoga, Naturopathy, Physiotherapy, Allopathic Medicine) Morning Stiffness Baseline Six Month Twelve Month Normal 10.30% 20.70% 89.70% Mild 32.80% 50.00% 10.30% Moderate 34.50% 29.30% 0.0% Severe 22.40% 0.0% 0.0% Swelling Normal 32.80% 58.60% 98.30% Mild 25.90% 32.80% 1.70% Moderate 31.00% 8.60% 0.00% Severe 10.30% 0.00% 0.00%

50 foot walk test: On comparing 50 foot walk test in intervention group, significant number of patients were able to complete the walk in ≤ 15 sec seconds at 6th (32.80%) and 12th (84.50%) as compared to baseline (1.70%), however, in control

group, number of patients (12.50%) and (3.10%) were able to complete the walk in ≤ 15 sec seconds at 6th and 12th month as compared to baseline 0.00%.

TABLE 6. Comparison on 50 foot walk test (Baseline, 6th and 12th month) in Control Group

Control group

50 Foot Walk test Baseline 6th Month 12th Month Unable 9.40% 3.10% 0.00% > 25 sec 31.20% 15.60% 9.40% 20.1 to 25 sec 46.90% 31.20% 53.10% 15.1 to 20 sec 12.50% 37.50% 34.40% ≤ to 15 sec 0.00% 12.50% 3.10%

TABLE 7. Comparison on 50 foot walk test (Baseline, 6th and 12th month) in Intervention Group

Group -II (Yoga, Naturopathy, Physiotherapy)

50 Foot Walk test Baseline Six Month Twelve Month Unable 5.20% 0.00% 0.00% > 25 sec 22.40% 1.70% 0.00% 20.1 to 25 sec 43.10% 17.20% 0.00% 15.1 to 20 sec 27.60% 48.30% 15.50% ≤ to 15 sec 1.70% 32.80% 84.50%

DISCUSSION This observation indicated that the combined treatment of yoga, naturopathy, physiotherapy and diets was an effective treatment for controlling OA of knees in old age patients. The combined therapy

of yoga, naturopathy, physiotherapy and diet control was safe and beneficial in reducing weight, BP, pain, morning stiffness, swelling and improving Vitamin D3, SF-12, 50 foot walk test scores in osteoarthritis of knee. Previous studies had

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focused on effect of yoga on OA patients. [14,15,16,17] A study done by Ebnezar et al., 2012 [18] had shown that reduction of pain (numerical rating scale) (P<0.001), morning stiffness (P<0.001) anxiety scores, BP and Pulse rate (P<0.001) were better in the yoga group than the control group. Similarly, all domains of SF-36 scores (P<0.004) were decreased more in the yoga group than the control group which was assessed after 15 and 90 days of yoga intervention as an adjunct to transcutaneous electrical stimulation and ultrasound treatment.[19] Another study, done on women having osteoarthritis of knee with hatha yoga, showed significant decreased in pain and symptoms, and increased daily activities and quality of life scores in the yoga group.[20] Furthermore, a pilot study, done on yoga, showed significant reductions in pain and disability caused by knee OA and it was suggested that yoga could be a feasible treatment option for OA of obese people.[21] The effect of Iyengar yoga in patients with OA hands had shown a better reduction in the pain during activity. [17] Likewise, our study had observed better reduction in pain, mornings stiffness, swelling and increament of functional activities. Evidence proved that yoga improved strength. So theoretically it should have beneficial effects for some musculoskeletal problems.[22] Massage therapy was another beneficial tool for improving OA of knee. Some of the previous studies had supported our findings. A randomised control trial study had demonstrated that participants who were having OA of the knee, benefitted from the self-massage intervention therapy. [23] After 2 weeks of massage therapy, it was reported that there was significant reduction of pain, fatigue and increased functional activities of daily living as compared with control group. [24] Hot and cold compress is considered to be useful treatment for OA of Knee. A study showed that pain scores were significantly reduced after using hot and cold compress. [11] Similar to our findings, contrast therapy has shown beneficial for treating OA of knees as significant improvement was found in reducing pain and morning stiffness in OA patients. [13] These results are in line with our findings. Some of the studies had proved that physiotherapy helped in improving pain and functional status. Bennell et al, studied the effect of physiotherapy in OA knee patients and documented improvement in pain by 70% in a 12 week follow up as compared to control group. [25] Physiotherapy reduced pain and improved in range of motion of patients with moderate to severe knee joint disease. [10] All these findings are almost similar with the results of our study. Result of this study showed improvement in SF-12 MCS, pain scores and vitamin D3 in both the groups. However Weight, BP, Swelling and

Morning Stiffness, SF-12 PCS scores were significantly improved only in the intervention group. The intriguing result of this study is that patients who received only combined package of yoga, naturopathy and physiotherapy without any allopathic medicine for one year had achieved better health than medicine group. Perhaps it is likely to happen that result of this study can be influenced by the attention of therapist and the participants’ expectations. Various studies had been carried out separately on effect of yoga, naturopathy as well as physiotherapy in the treatment OA of knees. However this is the first study which has been done to evaluate the effect of a combined package of yoga, naturopathy and physiotherapy along with diet control in the treatment of OA knees. CONCLUSION The integrated approach of yoga, naturopathy and physiotherapy along with diet is a beneficial cost effective treatment for controlling OA of knee since it has the potential to reduce pain, weight, BP, symptoms and, increase functional activities, Vitamin D3 effectively. Randomisation, equal sample size and more number of treatment sessions with the control group engaging in some prescribed physical activities were needed for further study to better compare the results. Acknowledgement Authors would like to thank Seed Division, Dept. of Science & Technology (DST), Govt. Of India, New Delhi for funding the research project and Dr. R. M. Nair, Director, Bapu Nature Cure Hospital & Yogashram, Mayur Vihar-1, New Delhi for providing research facilities. We also thank Dr. Ravi Pratap Singh, Physiotherapist for his contribution. REFERENCE

1. Ebnezar J, Bali Y, Nagarathna R, Nagendra H. Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study. Int J Yoga. 2011;4(2):55.

2. Chopra A, Patil J, Billempelly V, Relwani J, Tandle HS. Prevalence of rheumatic diseases in a rural population in western India: a WHO-ILAR COPCORD Study. J Assoc Physicians India . 2001 Feb 1;49:240–6.

3. Pal CP, Khanvilkar A, Deshpande A, Agashe A, Mankar A, Pathak D, et al. Study to Find the Prevalence of Knee Osteoarthritis In the Indian Population and Factors Associated with it . Agra; 2013.

4. Nair R, Kaushik G, N VG, Bhatnagar RK. Efficacy of Yoga Naturopathy and Physiotherapy inaImproving Morning Stiffness Pain VAS SF 12 MMT and Vitamin D3 in the Osteoarthritis of Knees or Elderly People. Int J Contemp Surg. 2015;3(2):44–9.

5. Javnbakht M, Hejazi Kenari R, Ghasemi M. Effects of yoga on depression and anxiety of women. Complement Ther Clin Pract . 2009 May;15(2):102–4.

6. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects

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of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: a randomized controlled study. J Altern Complement Med. 2012;18(5):463–72.

7. Ernst E. Complementary or alternative therapies for osteoarthritis. Nat Clin Pract Rheumatol. Nature Publishing Group; 2006 Feb;2(2):74–80.

8. Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Can Med Assoc J. 2000 Jun ;162(13):1815–20.

9. Peungsuwan P, Sermcheep P, Harnmontree P, Eungpinichpong W, Puntumetakul R, Chatchawan U, et al. The Effectiveness of Thai Exercise with Traditional Massage on the Pain, Walking Ability and QOL of Older People with Knee Osteoarthritis: A Randomized Controlled Trial in the Community. J Phys Ther Sci. 2014 ;26(1):139–44.

10. Marks R, Cantin D. Symptomatic Osteo-arthritis of the Knee: The Efficacy of Physiotherapy. Physiotherapy. 1997 Jun;83(6):306–12.

11. Denegar CR, Dougherty DR, Friedman JE, Schimizzi ME, Clark JE, Comstock BA, et al. Preferences for heat, cold, or contrast in patients with knee osteoarthritis affect treatment response. Clin Interv Aging . 2010 Jan ;5:199–206.

12. Calder A. The science behind Recovery Strategies for Athletes. SportsMed News. ; Availablefrom: http://www.ask.net.au/downloads/Update_on_Recovery_Techniques.pdf

13. Shehata AE, Fareed ME. Effect of Cold, Warm or Contrast Therapy on Controlling Knee Osteoarthritis Associated Problems. Int J Medical, Heal Biomed Bioeng Pharm Eng . 2013;7(9):518–24.

14. Taibi DM, Vitiello M V. Yoga for osteoarthritis: nursing and research considerations. J Gerontol Nurs . SLACK Incorporated; 2012 Jul 1;38(7):26–35.

15. Bukowski EL, Conway A, Glentz LA, Kurland K, Galantino M Lou. The effect of iyengar yoga and strengthening exercises for people living with osteoarthritis of the knee:

a case series. Int Q Community Health Educ . SAGE Publications; 2006 Jan 1;26(3):287–305.

16. Taibi DM, Vitiello M V. A pilot study of gentle yoga for sleep disturbance in women with osteoarthritis. Sleep Med . 2011 May ;12(5):512–7.

17. Garfinkel MS, Schumacher HR, Husain A, Levy M, Reshetar RA. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. J Rheumatol. 1994 Dec ;21(12):2341–3.

18. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: A randomized control study. Int J Yoga . 2012 Jan;5(1):28–36.

19. Ebnezar J, Nagarathna R, Bali Y, Nagendra HR. Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study. Int J Yoga . 2011 Jul;4(2):55–63.

20. Ghasemi GA, Golkar A, Marandi SM. Effects of hata yoga on knee osteoarthritis. Int J Prev Med . 2013 Apr ;4(1):133–8.

21. Kolasinski SL, Garfinkel M, Tsai AG, Matz W, Van Dyke A, Schumacher HR. Iyengar yoga for treating symptoms of osteoarthritis of the knees: a pilot study. J Altern Complement Med . 2005 Aug 30;11(4):689–93.

22. Garfinkel M, Schumacher HR. YOGA. Rheum Dis Clin North Am. Elsevier; 2000 Feb 2 ;26 (1):125–32.

23. Atkins D V, Eichler DA. The effects of self-massage on osteoarthritis of the knee: a randomized, controlled trial. Int J Ther Massage Bodywork . 2013 Jan ;6(1):4–14.

24. Kim I-J, Kim E-K. Effects of Aroma Massage on Pain, Activities of Daily Living and Fatigue in Patients with Knee Osteoarthritis. J muscle Jt Heal. Korean Society of Muscle and Joint Health; 2009 ;16(2):145–53.

25. Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell J, McColl G, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2005 Jun 1;64(6):906–12.

CITE THIS ARTICLE AS – Rukamani Nair et.al., Integrated Approach of Yoga, Naturopathy and Physiotherapy in the Management of Osteoarthritis of Knees, Int. J. Ayu. Alt. Med., 2016; 4(3):149-155 Source of Support – Financial grant for carrying out Research work: ICMR Conflict of Interest – None Declared

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CASE REPORT Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

PAIN MANAGEMENT BY PANCHAKARMA THERAPY W.S.R. TO CHRONIC LOW BACKACHE – A CASE STUDY

Bhingardive Kamini B.1*, Sarvade Dattatray 2, Santoshkumar Bhatted 3

1. PG Scholar, Dept. of Panchakarma, National institute of Ayurveda, Jaipur, India, Contact No. +917877736643, E-mail - [email protected]

2. PG scholar, Dept. of Dravyaguna, National institute of Ayurveda, Jaipur, India, Contact No. +919024937238, E-mail- [email protected]

3. H.O.D & Asso. Prof. Dept. of Panchakarma, National institute of Ayurveda, Jaipur, India, Contact

No. +919414048459, E-mail- [email protected]

Article Received on - 28th May 2016 Article Revised on - 18th July 2016 Article Accepted on - 25th July 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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CASE REPORT *Corresponding Author Bhingardive Kamini B. PG Scholar, Dept. of Panchakarma, National institute of Ayurveda, Jaipur, India, Contact No. +917877736643, E-mail - [email protected]

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ABSTRACT: Current study is carried out to find out the combined effect of certain classical

Panchakarma treatment like Kati Basti, Dashamoola Basti in a case of chronic low back pain. A female patient aged 52years was admitted in the I.P.D. of Panchakarma dept. of NIA Jaipur, presented with the complaints of low back pain with difficulty in sitting and standing since 2 years associated with anorexia, B/L knee joint pain since 2-3 months. This condition can be correlated to the symptom of Katishoola described in Ayurveda which is one of the VataVyadhi. Ayurveda provide range of treatment especially Panchakarma, so patient was treated with Kati Basti and Dashamoola Basti in Yoga Basti schedule (total 8 basti) accompanied by certain conventional oral medication. Low backache reduced, back stiffness reduced, mild relief was found in B/L knee joint pain, range of movement of spine increased. It can be concluded that Panchakarma treatment is effective in pain management of low backache patients.

Key Words: Kati Basti, DashmoolaBasti, Katishoola, Low backache

INTRODUCTION Low back pain (LBP) is pain, muscle tension, or stiffness, localized below the costal margin and above the inferior gluteal folds, with or without referred or radicular leg pain (sciatica). [1] The most important symptoms of LBP are pain and disability (activity limitation). Aging is a well-known risk factor of LBP as degenerative changes in the spine and disc are one of the major causes of LBP. [2] Low back pain is one of the major causes of activity limitation and work absence throughout much of the world. [3] It is the second most common reason for visits to physicians. [4] The point prevalence of LBP is 28.5% found in an Asian country. [5] About 70% people have the chance of developing LBP at least once in life. [6] In Ayurveda this condition can be correlated with Katishoola which is one of the Vatavyadhi. It is classical fact that this pain is effectively relieved by Basti, swedana etc. In it`s counterpart, the management by modern medicine for this condition is by conservative treatment like rest, immobilization, use of analgesics, anti-inflammatory drugs, physiotherapy or surgical in later course of the disease. If the pain and neurological defect may not subside on prolonged conservative treatment finally surgery is considered which not a right choice. So we have used Ayurvedic modality to treat the disease. CASE REPORT A female patient aged 52 years was admitted in the I.P.D. of Panchakarma dept. NIA Jaipur, presented with the complaint of low backache with difficulty

in sitting and standing since 2 years associated with anorexia, B/L knee joint pain since 2-3 months. By taking detailed clinical history patient was having accidental trauma on back region and after that gradually above symptoms appears. She took Allopathic regimen for symptomatic relief. Now again she was suffering with same complains since 2 month. This history of the patient revealed the chronicity of the disease. OBSERVATIONS Signs: -Tenderness in lumbo-sacral area, S.L.R test negative, femoral stretch test was positive. Symptoms: - Localised shooting type of pain in lower back region without radiating to lower limb, associated with anorexia, B/L knee joint pain.

Prakriti: - Kapha- Vata. Vaya: - Madhyavastha Bala: - Madhyama Agni: - Manda Koshtha: - Madhyama

Lab investigation positive findings:- ESR-32 mm/hr CRP- positive Treatment given: Kati Basti: - The procedure of applying heat to the sacral or lumbar region by retaining warm medicated oil within a specially formed frame on this area is known as Kati Basti. It is indicated in painful condition of low back region. [7]

PAIN MANAGEMENT BY PANCHAKARMA THERAPY W.S.R. TO CHRONIC LOW BACKACHE – A CASE STUDY

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The procedure was done with DashamoolaTailam, 30 minutes per setting for duration of 15 days. Basti Karma:- NiruhaBasti: - The composition of the medicine administered in the form of Basti contains Dashamoola Kwath (herbal decoction), Sneha (medicated Oil/Ghee), Madhu (Honey), Saindhava Lavana (rock salt) and Kalka (herbal paste). [8]

Dashamoola Basti was given in Yoga Basti schedule (8 days) with the following contents. Madhu -60gms Saindhava lavana -05 gms Dashamoola tailam-90ml Shatapushpa Kalka -30gms Dashamoola kwatha -240 ml The contents of Dashamoola Kwatha are Bilva (Aegle marmelos(L.) Correa ex Roxb.), Agnimantha (Premna mucronata Linn.), Shyonaka (Oroxylum indicum(Linn) Vent.), Patala (Stereospermum suaveolens (Roxb.) DC.), Gambhari (Gmelina arborea Roxb.), Shaliparni (Desmodium gangeticum (L.) DC.), Prishnaparni (Urariapicta Desv.), Brihati (Solanum indicum Linn.), Kantakari (Solanum nigrum Linn.), Gokshura (Tribulus terrestris Linn. ) Anuvasana Basti:- Administration of medicated oil or other fat through the rectal route in a prescribed dose is called as Anuvasana Basti. In this case study Dashmoola taila was used for Anuvasana Basti. Shamana Aushadhi: - Palliative treatment with

1) Simhanada Guggulu - 2 pills (500 mgm) thrice in a day

2) Rasnasaptaka Kwath – 5gm thrice a day

3) Ashwagandha Churna 2gms +Gokshura 2gm+ Chopchini - 500mg thrice in a day

4) Tarunikusumakar Churna5 gm.at bed time with Luke warm water.

RESULT Relief was found in Low back pain and stiffness with increased range of movement of spine. Mild relief was found in B/L knee joint pain. DISCUSSION Basti Karma is said to be the Ardha Chikitsa or even Poorna Chikitsa among all the Snehadi Karma, as Vata Dosha is the sole responsible entity for pathology pertaining to Shakha, Koshtha, Marma, Urdhvanga and Sarvaanga Avayava and as it does Vikshepa as well as Sanghata of Dosha, Dooshya

and Mala.Ayurveda has the privilege of offering the best remedies for low back pain and related painful conditions. Katishoola is one Among Vata Vikara. Basti Chikitsa is the best treatment for correcting Vata Dosha, further Dashamoola Basti was selected as it possesses properties like tridosha shamaka, Shothahara, Shoola prashamana which help in reduction of inflammation and pain. Especially Dashamoola taila used as Sneha in Basti corrects the degeneration that took place at the level of disc by virtue of Snigdha guna and Balya and Brimhana action. Kati Basti: Keeping warm medicated oil on lumbar region for specific time period is known as Kati Basti. It is a combination of Snehana and Svedana which is the first line of treatment for Vata Dosha. The hot medicated oil increases the circulation in the localized region and helps in deep absorption into the skin which nourishes and strengthens the muscles and nerves. It also pacifies one of the primary sites of Vata by relieving pain, tension and restoring flexibility of spine. The Dashamoola Taila used in Kati Basti is shothaghna and Snehana in nature helps to overcome the accumulation of Vata at the site of pathology and may nourish the underlying tissue. Shamana drugs: - Mainly Aamapachana, Shothahara, Brimhana properties reduces the Shotha and helps in prevention of further degeneration of Asthi and Majja Dhatu. Vatahara property might have helped to overcome degeneration of disc and prevent further Vata Prakopa. CONCLUSION On the basis of this single case study, it can be concluded that Panchakarma treatments like Kati Basti, Dashamoola Yoga Basti has been effective in the pain management of low backache patients thereby improving quality of life. REFERENCES

1. Van der Heijden GJMG, Bouter LM, Terpstra-Lindeman E. The efficacy of traction for low back pain: results of a randomized blinded pilot study. Ned T Fysiotherapie1991; 101: 37-43.

2. Lawrence A, Rafael HL, Simeon M. Back pain and osteoporosis. In: John Hopkins White Papers, 1-37, Rebus, 2003. New York:

3. Lidgren L. The bone and joint decade 2000-2010. Bull WorldHealth Organ 2003; 81:629.

4. Sharma SC, Singh R, Sharma AK, Mittal R. Incidence of low back pain in work age adults in rural North India. Indian J Med Sci2003; 57: 145-7

5. Tomita S, Arphorn S, Muto T, et al. Prevalence and risk factors of low back pain among Thai and Myanmar migrant sea food processing factory workers in Samut Sakorn Province, Thailand. Ind Health 2010; 48: 283-91.

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6. Van Tulder M, Becker A, Bekkering T, et al. European guidelinesfor the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 15: 169-91.

7. Dr. G. Shrinivasa Acharya, Panchakarma Illustrated, first edition 2006, Choukhambha Sanskrit Pratishthan, Delhi, ISBN-81,7084-3079,p.254.

8. Dr. Shukla V., Dr. Tripathi R.D., Charaka Samhita Siddhisthana, Chapter 03/23; Varanasi: Chaukhamba Surbharati Prakashan; Reprint 2010; p.901

CITE THIS ARTICLE AS – Bhingardive K. B. et.al., Pain Management by Panchakarma Therapy w.s.r. to chronic Low Backache – A Case Study, Int. J. Ayu. Alt. Med., 2016; 4(3):156-159 Source of Support – Nil Conflict of Interest – None Declared

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Sawant S.U. et.al., Effective Ayurvedic Management for Calcaneal Spur –A Case Study, Int. J. Ayu. Alt. Med., 2016; 4(3):160-163

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CASE REPORT Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

EFFECTIVE AYURVEDIC MANAGEMENT FOR CALCANEAL SPUR –A CASE STUDY

Sawant Shreya Umesh1*, Jayant Subhash Hartalkar2, Sawant Umesh Vasant3

1. Associate Professor, Dept. of Rachana Sharir, D. Y. Patil School of Ayurved, Nerul, Contact No. +91 9833696119, Email- [email protected]

2. Associate Professor, Dept. of Rachana Sharir, D. Y. Patil School of Ayurved,Nerul, Contact No. +91

9920956434, Email- [email protected]

3. Professor, Dept. of Rachana Sharir, Mahila Ayurved Medical College, Yamuna Nagar, Haryana, Contact No. +91 9833821258, Email- [email protected]

Article Received on - 11th Aug 2016 Article Revised on - 23rd Aug 2016 Article Accepted on - 29th Aug 2016

All articles published in IJAAM are peer-reviewed and can be downloaded, printed and distributed freely for non commercial purpose (see copyright notice below).

(Full Text Available @ www.ijaam.org)

© 2013 IJAAM This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en_US), which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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CASE REPORT *Corresponding Author Sawant Shreya Umesh Associate Professor, Dept. of Rachana Sharir, D. Y. Patil School of Ayurved, Nerul, Contact No. +91 9833696119, Email- [email protected]

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ABSTRACT: The most common form of heel pain is mainly due to calcaneal spur. It is one of the

most troublesome common health complaint usually affects badly peoples routine work, and once it is manifested very difficult for the body to heal. The pathophysiology of calcaneal spurs is poorly understood. The association between calcaneal spurs and heel pain has led to the development of several interventions directly targeted at the spur, including surgical excision, extracorporeal shockwave therapy and radiation therapy. In Ayurveda, it can cure successfully and can avoid injections, surgery and other proceeding complications. A patient of calcaneal spur successfully treated with Ayurvedic methods is presented in this case study.

Key Words: Calcaneal spurs Ayurvedic management

INTRODUCTION The most common form of heel pain is mainly due to calcaneal spur. It is one of the most troublesome common health complaint usually affects badly peoples routine work, and once it is manifested very difficult for the body to heal.[1] A large percentage of people suffer from this disease. This is most often seen in the patients. Although initially considered to be an abnormal finding inextricably linked to heel pain, more recent studies have reported that between 11 and 16% of the general population has radiographic evidence of calcaneal spurs. [2]

Calcaneal spur (or heel spur) is a small osteophyte (bone spur) located on the calcaneus (heel bone). Calcaneal spurs are typically detected by a radiological examination (X-ray).The pathophysiology of calcaneal spurs is poorly understood. When a foot bone is exposed to constant stress, calcium deposits build up on the bottom of the heel bone. Generally, this has no effect on a person's daily life. However, repeated damage can cause these deposits to pile up on each other, causing a spur-shaped deformity, called a calcaneal (or heel) spur. Obese people, flatfooted people, and people who often wear high-heeled shoes are most susceptible to heel spurs.[3]

An inferior calcaneal spur is located on the inferior aspect of the calcaneus and is typically a response to plantar fasciitis over a period, but may also be associated with ankylosing spondylitis (typically in children). The association between calcaneal spurs and heel pain has led to the development of several

interventions directly targeted at the spur, including surgical excision, extracorporeal shockwave therapy and radiation therapy.[4]Possible complications of surgery include nerve pain, recurrent heel pain, permanent numbness of the area, infection and scarring. In addition with plantar fascia release, there is risk of instability, foot cramps, stress fracture, and tendinitis. In Ayurveda, it can cure successfully and can avoid injections, surgery and other proceeding complications.A patient of calcaneal spur successfully treated with Ayurvedic methods is presented in this case study. CASE REPORT A Female patient of Right Calcaneal spur Age: 38Yrs, Wt. – 58 kg, Occupation – Housewife Modern Medicines taken for 1 yr for the same. Due to temporary results and side effects such as Hyperacidity, patient came for Ayurvedic treatment in clinic.(Dadar, Mumbai) C/O: Right Heel pain, since 1 yr. Heel pain is more severe when waking up in the morning and also from rest and pain relieved after few steps. After a short step a dull pain persist. Sometimes knife sticking type of pain H/O: Hyper Acidity since 6 months. No H/O OF B.P., Diabetes Menstrual History: Regular O/E: tenderness over affected area when palpate. P/A: Soft, Tongue: Coated

EFFECTIVE AYURVEDIC MANAGEMENT FOR CALCANEAL SPUR –A CASE STUDY

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Pulse: 86/min, B.P.: 140/80 mm of Hg

INVESTIGATIONS –

Rx for 15 days 1. Padmakashta churna 250 mg TDS after food. 2. Yograj guggul 2 tab with worm water BD

after food. 3. Avipattikar churna 1 tsf at bed time with

warm water 4. Agnikarma by Mruttika shalaka on painful site

at Right heel. 5. Ishtika Sweda (Brick Fomentation) is advised

daily for 10-15 min. Following instructions were given to the patient: give proper rest Use proper fitted footwear with having heel

arch and support. Avoid bare foot walk especially in hard floor. Avoid high heeled foot wear. Avoid standing for long. Avoid excessive intake of hot and spicy foods.

etc Follow up after 15 days: O/E: Pain during standing for a long time Tenderness over affected area - Reduced

Pain during walking - Reduced Acidity – Reduced No Constipation From above symptoms Treatment is changed - for 30 days,

1. Yograj guggul 2 tab BD after food. 2. Gokshuradi guggul 2 tab BD Before food 3. Avipattikar churna 1 tsf at bed time with

warm water 4. Ishtika Sweda (Brick Fomentation) is advised

daily for 10-15 min. Follow up after 30 days: O/E: No pain during walking, standing for a long time No tenderness on affected area on Rt Heel No Acidity No Constipation Investigation: X ray shows absence of calcaneal spur. Same Treatment is continued for next 15 days RESULTS AND OBSERVATIONS

Table No.1: Results & Observations

Sr. No. Sign & Symptoms Before Treatment

After 15 days

treatment

After 30 days

treatment 1 Hyper acidity × ×

2 Rt Heel pain during walking × ×

3 Rt Heel pain during standing for a long time ×

4 Tenderness at affected area × ×

5 Spur on Rt calcaneum in X ray X ray Not

done ×

Fig. 1: X ray findings before and after treatment

DISCUSSION According to Ayurveda this condition may be due to Kapha dosha vitiation along with Vata dosha. As

a result Kapha dushti/vitiation bone formation in that area malfunctions and lead to inflammation etc. excess calcium deposition and spur formation

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Sawant S.U. et.al., Effective Ayurvedic Management for Calcaneal Spur –A Case Study, Int. J. Ayu. Alt. Med., 2016; 4(3):160-163

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occurs. This vitiated kapha block or alter the normal path of the Vata srotas/channels. Vata has the main dosha in three of them and has the main functions like movement, neurological and motor activities. The vitiated Vata also causes pain. Patient had acidity before treatment, so for Padmakashta churna is used in first 15 day as it is Vata and Pittahar.[5] Avipattikar churna is used for pitta shamak as it is mentioned in amlapitta rogadhikar.[6]As calcaneal pain is produced by vitiation of Vata Dosha, Yograj guggul is used as it is mentioned in Vataroga.[7] As per Panchabhautik chikitsa, Gokshuradi Guggul is used and also for Kleda vahan in Apana Kala.[8] Agnikarma is a type cauterization method, following internal medicines gives dramatic change to the patient. It gives instant pain relief. The easiest form of Swedana is Ishtika sweda. It can be performed by the patient itself at home, because it is simple and cost effective. All medicines are used which especially act on Vata Dosha. CONCLUSION There are very good medicines available for the calcaneal spur in Ayurved which gives better results than modern medicines. Also, modern medicines may develop some side effects which are hazardous. Ayurvedic treatment is the safest and successful treatment offered till date which is

result oriented and is side effect free. Ayurveda is considered such treatment as it’s an herb based treatment and known to be work on internal reasons to rectify the problem from roots. Calcaneal spur can be successfully treated by using Vata shamak, Raktaprasadak Dravyas and Agnikarma. In Ayurveda it can cure successfully and can avoid injections, surgery and other proceeding complications. ACKNOWLEDGEMENT Author acknowledges all parent and colleagues who helped a lot in making this Article very effective in very short time. Acknowledge co-author for his valuable Contribution. REFERENCES

1. https://www.vaidyaveekshana.blogspot.com [ Assessed date : 07 /08/ 2016]

2. https://jfootanklers.biomedcentral.com/article,[Assesseddate:07/08/2016]

3. https://en.wikipedia.org/wiki/Calanealspur,[Assesseddate:08/08/2016]

4. https://jfootanklers.biomedcentral.com/article, [ Assessed date :0 7 /08/ 2016]

5. Vaidya Ganesh Garde, Ashtang Hridaya, Anmol Prakashan, edition 2003, p.67

6. Vaidya Govind Das, Bhaishajya Ratnavali, Chaukhambha Prakashan, Varanasi, edition, 2010, p. 903

7. K. R. Shrikantha Murthy, Sharandhar Samhita, Chaukhambha Prakashan, Varanasi, edition, 2007, p.106

8. Ibid., p.109

CITE THIS ARTICLE AS –

Sawant S.U. et.al., Effective Ayurvedic Management for Calcaneal Spur –A Case Study, Int. J. Ayu. Alt. Med., 2016; 4(3):160-163 Source of Support – Nil Conflict of Interest – None Declared

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CONFERENCES / SEMINARS / SYMPOSIA

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CONFERENCES / SEMINARS / SYMPOSIA Scientific Journal Impact Factor 5.733 (2015) by InnoSpace Sci. Res., Morocco

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